IM Clinics History 2
IM Clinics History 2
IM Clinics History 2
2010
Internal Medicine Clinics
January
18,
Both of his parents are hypertensive and both are on maintenance drugs. His
father also has diabetes and is on medication. There are no other heredofamilial
diseases like cancer, familial hypercholesterolemia or psychological illnesses.
PERSONAL/SOCIAL HISTORY
The patient is the eldest in the brood of four. He took three different courses in
college but was not able to finish any course. He took pharmacy for one semester
only then electrical engineering for another semester and one year for associate
computer course. He got married at the age of 17 and he was widowed when his
wife died while giving birth to their second child in 2007. He is a non-smoker and
was an alcoholic drinker for a year preferably hard beverages like Tanduay Rhum
consuming 1 bottle per session. He has no food preferences except for foods that he
has allergy on. He enrolled himself in a gym before for a year and 3 months but
now, he does not exercise anymore.
He lives with 25 other men in a room with 2 common comfort rooms in
building where they train for gospel studies. Water source is from NAWASA and they
have mineral water for drinking.
REVIEW OF SYSTEMS
General: Patient is awake, conscious, coherent and conversant. He is sitting and
afebrile. He weighs 63 kilos.
Skin: Patient has no complaints made regarding rashes and itchiness. He claims to
have no masses or lesions on the skin.
Head: The patient has migraine accompanied by bleeding of the nose, no
medications taken when there is attack. The patient does not experience hair
shedding and itching of the scalp.
Eyes: Patient wears reading eyeglasses with a grade of +1.00 on both eyes which
started in 2007.
Ears: He claims to have no discharges on both ears and does not have tinnitus.
Nose and sinuses: He does not have any stuffed sinuses and claims that he has
good sense of smell. He experiences nose bleeding whenever he has migraine.
Neck: No complaints made regarding the neck area like swollen lymph nodes and
pain.
Mouth and Throat: Patient does not have difficulty of swallowing. No dryness of
the mouth.
Respiratory: Patient claims that he experiences occasional difficulty of breathing
due to stress, cough and phlegm.
Cardiovascular: The patient feels chest heaviness, easy fatigability and
palpitations. He does not experience orthopnea.
Gastrointestinal: The patient claims that he has a good appetite. He does not
have any food intolerance. Good bowel movement.
Urinary: Urine is straw to colorless in appearance. Patient does not experience
dribbling, burning sensation, and pain upon urination. Urine flow is continuous and
the caliber is of normal size.
Genital: The patient has no hernia, ulcer or lesions as claimed. He claims to have
no any form of discharge.
Peripheral Vascular: Patient does not complain of having cramps and varicosities.
There are no bruising and edema.
Musculoskeletal: No complaints made regarding joint and muscle pains.
Hematologic: The patient claims that he does not easily bruise and he has good
wound healing.
Neurologic: Negative for blackouts, seizures and tingling sensations.
Psychiatric: Patient claims to have no mood swings or depression. He has no
history of hallucinations and memory changes. No suicidal attempts and ideations.
Sleep pattern is normal.
Endocrine: Patient claims to have heat intolerance and excessive thirst.
PHYSICAL EXAMINATION
General Survey
Patient is awake, sitting, coherent and conversant. He responds spontaneously to
voice stimuli. Patient is 5 feet 3 inches tall and weighs 63 kilos having a BMI of 24.6
which is normal.
Vital Signs
Patients Blood pressure is 120/80mmHg, temperature of 36.2 C, respiratory rate of
22 breaths per minute, pulse rate of 53 beats per minute and cardiac auscultatory
rate of 54 beats per minute.
Skin
Skin is warm to touch and has a good turgor. Body hair is evenly distributed. Finger
and toe nails are have good capillary refill time. There are no wounds and lesions
noted.
HEENT
Head: Face is round in shape, symmetric. Hair is of average quantity and texture,
black in color. No mass, tenderness and any scalp lesions.
Eye: Pupils are round, equal in size. Both are reactive to pupillary and consensual
reflexes. Eyebrows are well distributed. Conjunctiva is pale, sclera is white.
Ear: No lumps, tenderness and redness noted. Ear has no discharges. Tympanic
membranes were not checked.
Nose and sinuses: Nose is normal in size and symmetrical. Nasal mucosa, septum
and turbinates were normal and without any secretions. There is no sinus
tenderness.
Throat: Oral mucosa is pink with complete set of teeth. Tongue at the midline on
protrusion. There were no lesions and tenderness. Lips and mucosa are well
hydrated. Tonsils were not enlarged.
Neck
No cervical lymph node enlargement and no masses noted upon palpation. Trachea
is at the midline. Lobes of the thyroid glands are not palpable.
Lymph Nodes
Cervical nodes were not enlarged. Axillary and inguinal nodes were not palpated.
Thorax and Lungs
Chest is symmetrical with limited chest expansion due to abdominal tenderness. No
tactile fremitus on palpation. Lungs are resonant. Normal breath sounds. No
wheezes or rales.
Cardiovascular
PMI at 5th ICS, MCL. No thrills or heaves. No murmurs or extra sounds.
Abdomen
Flat abdomen. Normoactive bowel sounds. Percussion and palpation were not done
due to tenderness.
Genitalia: Examination not done
Rectal: Examination not done
Extremities
All extremities of the patient exhibited fair strength and without edema.
Peripheral vascular
No varicosities noted. Irregular pulse on radial and dorsalis pedis.
Musculoskeletal: Patient has a good range of motion on all extremities.