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Running head: COMPREHENSIVE HISTORY & PHYSICAL 1

Comprehensive history and physical worksheet


Your name:
Anne Waskiewicz

Chief complaint (this is what the patient came in for if they have no particular complaints it may be
well visit, yearly physical or similar):
Well visit, patient states I am unable to lose weight since birth of my son.

History of present illness- MUST include the 10 characteristics of a chief complain OR list each and
note not applicable- you MUST specify WHAT the characteristics are please review your text, p. 47:

Location Overall body


Radiationnot applicable to chief complaint
Quality Patient states, I feel like I cant lose weight no matter how hard I try
QuantityAffects all aspects of daily life
Associated manifestations-- sluggish, irritable, inability to sleep
Aggravating factorsintake greater than calories expended
Alleviating factorsnot applicable
SettingDaily life
TimingWeight gain occurred during pregnancy
Meaning and Impactfinancial with new wardrobe
ImpactSelf-esteem and body image

Past medical/surgical history must include childhood illnesses, chronic illnesses/diseases,


injuries/accidents, blood transfusions, special needs, prior surgeries or asked and N/A you MUST
list each of these and describe in order to receive full credit. Do not leave it blank because it is
negative list it and then note none:

Childhood disease Chicken pox, age 6


2004--concussion while playing rugby
2005--Right rotator cuff syndrome due to overuse
9/5/2016 vacuum assisted vaginal delivery of baby boy
12/2016 laparoscopic endometrial ablation/resection and endometrial cystectomy
CurrentGastroesophageal reflux disease (GERD)
Current--Polycystic breast syndrome

Allergies: List food AND drug AND environmental offending agent AND reaction must be noted or
asked and N/A specified for each you MUST list out EACH of these and specify either none or the
allergen AND reaction to receive credit:

FoodN/A
DrugN/A
EnvironmentalN/A
COMPREHENSIVE HISTORY AND PHYSICAL 2

Current medications for each, list: Drug, Dose, Frequency, Reason for use, Length of use or asked
and N/A. Include both prescription and OTC meds. You can add rows to this table if you need to by
right-clicking on the bottom row and selecting insert rows below:
Drug Dose Frequency Reason for Use Length of Use
Prenatal vitamin general Once a day Future pregnancy 2 years
Flaxseed oil 1000 mg Once a day Omega 3 4 years
supplement
Vitamin D3 1000 IU Once a day Bone/Immune 5 years
Support

Family health history include: age and health of children, siblings, parents; familial or genetic diseases-
at a minimum, note presence/absence of cancer, diabetes, heart disease. You can add rows to this table
if you need to by right-clicking on the bottom row and selecting insert rows below. You MUST fill in
each row for their family members so if there is no pertinent history, specify none. Make sure to
edit the family members in the column as appropriate, and include their age. :
Disease: Cancer Diabetes Heart Disease Other
Mother Breast (mortality) Gestational None Deceased age 39
Father Skin None Myocardial Deceased age 56
Infarction and
hypertension
Sibling None None None Brother, age 34
ADHD
Sibling None None None Brother, age 27
Obesity, autism,
sleep apnea
Child None None None Age 18 months
Child n/a n/a n/a n/a
AUNT Breast (mortality) Medication None Deceased, age 68
induced

Social history: ETOH use (type, amount, length of use, CAGE screen), Tobacco use (type, amount, length
of use), Drug use (type, amount, length of use), Presence/absence of domestic violence, sexual
orientation/birth control/number of partners (depending on the patient, this may be deferred, but
specify that you considered it and your rationale for deferring the question), type of employment,
education level, economic status:
CAGE Screen C Yes, when I A No G No E No
(review p. 59 of was pregnant
your text and
complete the four
sections to the
right):
Tobacco use: rarely Type: cigar Amount: 1 Length of use:
celebratory 1 a
year
COMPREHENSIVE HISTORY AND PHYSICAL 3

Drug use: None Type: Amount: Length of use:


Presence/absence domestic violence? None
Sexual orientation? Heterosexual
Birth control? No Number of partners? 1
Type of employment Education Level Socioeconomic Status

Ophthalmic technician 4-year college Middle Class


Bachelor of Science Degree

Spiritual assessment FICA (see p. 184 of your text for complete listing of questions):
Faith and Belief:
Do you consider yourself spiritual or religious? Yes

Do you practice a specific faith? Yes

Do you have spiritual/religious beliefs that help Yes


you cope with stress?

What gives your life meaning? God


Family
Church

Importance:
What importance does your faith or belief have It gives my life meaning, structure and a social
in your life? outlet.

Have your beliefs influenced how you take care Yes


of your health?

What role do your beliefs have in regaining or My beliefs act as a framework how to be
maintaining your health? respectful of others and maintain integrity in my
relationships.

Community:
Are you part of a spiritual or Yes active members within a local church
religious community?

Does this group support you? Yes


How? through friendship provide meals in times of need
emotional support via Bible study
COMPREHENSIVE HISTORY AND PHYSICAL 4

counseling sessions
Is there a group of people you Yes
really love or who are important family
to you? friends
church family

Address:
How would you like the healthcare team to Guidance and lifestyle ideas
address these issues in your healthcare? Provide counseling
refer to specialist
provide educational literature
accountability between provider and
patient/patient family

Cultural assessment EACAT (see p. 143-144 of your text for complete listing of questions):
Ethnic group affiliation and racial background:
Would you tell me how long you have lived here Bowie, Maryland7 years
in_____?

Where are you from originally/where were you Born in Washington, DC and raised in Waldorf,
born? MD

With which ethnic group do you identify? How I am a patriotic American and proud to live in
strongly? the land of the free.

Where have you lived and when? Did you have Waldorf, MD from 1986-2004.
health problems or exposures in any of those I had chicken pox while a child for ten
places? How did you recover? days with no lasting effects.
2004-2008 lived in St Marys City
(attending college, minor concussion
while playing Rugby with no long- term
injuries.
2008-2009 lived in Frederick, MD
2010-present resides in Bowie, MD

Major beliefs and values:


What is your time orientation (past, present, Time orientation: I always look and plan
future?) What do you think is the basic nature of for the future.
human beings? What is the purpose of life and Basic nature of human beings are
human relations? What should be the physical, emotional and spiritual needs
relationship between humans and nature? Purpose of life and human relations is to
survive
The relationship between humans and
nature should be able to co-exist
peacefully
COMPREHENSIVE HISTORY AND PHYSICAL 5

Do you practice any special activities as part of I incorporate fun, memory making celebrations to
your cultural traditions? mark milestones in the lives of our family and
friends by:
celebrate birthdays
Christmas
Easter
Thanksgiving
Family traditions related to Polish
cooking,
Gingerbread man decorating contest
What are your beliefs, customs, values, practices I believe men and women should be well
related to work, education, leisure? educated. Women should have the freedom to
work outside the home and receive equal pay for
equal work.

Health beliefs and practices:


What does being healthy mean to you? Being healthy means, feeling good in your body
and being at a healthy weight.

What do you believe promotes being healthy? I believe the following promote being healthy.
Laughter
Relaxation
Proper amount of sleep
What do you do to help you stay healthy? Eat a healthy meal,
exercise 2-3 times a week
10000 steps a day
8 hours of sleep.
What does being ill or sick mean to you? Sick means (i.e. like a cold or a stomach bug) that
keep you from enjoying daily activities at work or
home
What do you believe causes illness? Illness can be caused by an exposure to
germs
genetic mutations,
immune resistance is compromised
What do you usually do when you are sick or not Sleep is a priority when I feel sick whether it is a
feeling well? gastrointestinal virus or the common cold.
I take vitamins(zinc/Vitamin C), drink plenty of
fluid to stay hydrated.
When you are sick or not feeling well, who do Urgent Care Center. They are very helpful
you go to for help? How helpful are they, and for treating sinus infections, and minor illnesses.
what types of problems?

Who determines when you are sick or not? Who I determine when I am sick.
do you want to be with you when you are sick? I want my husband to wait on me hand
and foot and take care of the baby also.
Who in your family is responsible for making Patient and spouse share responsibility.
COMPREHENSIVE HISTORY AND PHYSICAL 6

healthcare decisions, and who should be involved Who should be involved in teaching about
in teaching about your specific health problems? specific health problems:
Primary Care Physician
Nurse practitioners
Genetic Counselor
What are your beliefs about mental illness, They are a fact of life and must be dealt with
chronic disease, handicapping conditions, pain, throughout the course of life.
dying, and death?
Are there any cultural or ethnic sanctions or No
restrictions that you want to observe?
By whom do you prefer to have your healthcare Physician. I do not have a preference regarding
provided (nurse, physician, etc?). Do you prefer age, gender or cultural background. I want my
them to be of the same cultural background, age, physician to be competent and available.
or gender as your own?

Language barriers and communication styles:


What languages do you speak/read? In what English
language are you most comfortable French
communicating? American Sign Language
English is the preferred language
Do you prefer to have an interpreter when N/A
discussing healthcare information and
treatments?
Are there any special ways of showing respect or Yes
disrespect in your culture? Eye contact
Sincerity
Genuine
Authentic
Are there any cultural preferences/restrictions No
related to touching, social distance, eye contact,
or other verbal/nonverbal behaviors?
Are there culturally appropriate forms of greeting Yes
or parting, topic restrictions, or visiting times? Hand shake
Eye Contact

Role of the family, spousal relationship, and parenting styles


What is the composition of your family? Who is Immediate Family
considered a family member? Wife
Husband
Son
Brother (27 year- old) resides in the
household
Extended Family
Mother and Father-in-Law
Sisters-in-law
Aunt and Uncles
COMPREHENSIVE HISTORY AND PHYSICAL 7

Cousins
With what ethnic groups does your family as a American
whole identify? Polish
French
Scottish
Which of your relatives live nearby? With which Father and mother-in-law
of your family members and relatives do you Brothers family
interact most often? Local brother and sister-in-law,
2 nieces and 2 nephews (weekly)
Interactions:
Weekly interactions in person or by
phone
How do your family members interact related to Equitable distribution of responsibilities in
chores, mealtimes, childcare, recreation, etc? Are relation to
you satisfied with this? Mealtimes
Childcare
Recreation
Chores are a consistent challenge with
brother who lives with us. He must be
reminded weekly of his responsibilities
Overall, I am satisfied.
What major events are most important to your Birthdays
family, and how do you celebrate them? Wedding anniversary
Family reunion
Traditional Polish Holiday
celebration(Christmas/Easter)
Annual canoe trip
Camping trip
Celebrate major events:
A party
A special get-away for two
Picnics at a Park
Family get-together with lots of food and
fun
Camping with family or extended family
What are your familys goals for the health and Goals/Dreams: Be in the 26% BMI range. I want
well-being of the whole family? What are your to be a healthy family that minimizes health
future dreams? How do you work toward these? problems through intentional living.
What are the barriers? Steps to Achieve these goals: We currently have
chosen a vegetarian lifestyle.
To achieve this goal of 26% BMI
we must eat healthy,
decrease carbohydrates and
decrease sweet intake
increase activity level
decrease sedentary lifestyle
COMPREHENSIVE HISTORY AND PHYSICAL 8

We can work toward this goal by


keep a daily log of food and drink intake
Daily log of activities
We can use technology with Fitbit
trackers or apps on our cellphone
We will encourage walks
cycling at least three times a week
mow the lawn
yard work during the spring and summer
months.
Barriers:
Time management
Maintain a balance between work
spending quality family time
outside commitments
How can the healthcare team help you work Counseling.
toward these goals? Proactive participation in genetic testing because
of the BRACA gene in my family history.
With what social groups (church, work, etc) does Yearly physicals and necessary testing
your family interact, and what is the nature of yearly dental visits
these interactions? every three years eye appointments

Social groups:
church worship service
small group
Sunday School teacher
yearly ladies retreat and
family and friends
Nature of the interaction is fellowship in weekly
service and then getting together with others
during the week whether it be in Bible Study or
play time with children.
Work interaction is primarily professional with
occasional after hour get togethers.
Family interactions are regular monthly dinners
for our local family. Share child care services.
Take nephew and niece landscape painting
expeditions.
How does your family practice any special beliefs Family practice:
related to marriage, conception, pregnancy, Marriage monogamous
childbirth, breastfeeding, baptism, childcare, Do not believe in divorce
puberty, separation, divorce, health, illness, Do not believe in abortion
death? Children are a blessing
Breastfeed is preferred method
Childcare both parents involved in best
practice for the children
COMPREHENSIVE HISTORY AND PHYSICAL 9

Mother-in-law watches grandson one day


every week.
Church member watches child one day a
week
What are the family members health and social Major stressorsblended family,
histories - habits, major stressors, work patterns, Work patterns: committed to time necessary to
religion/community/recreation patterns? fulfill work commitment but flexible when
unexpected needs (sickness, death, childcare
issues) arise.
Recreation patterns:
board games
hiking
biking
tent camping
canoeing
annual vacation

Religious influences or special rituals; dietary practices - covered elsewhere and do not need to be
addressed here.
Nutritional assessment (see rubric, text table 7-7 on p. 220):
General diet information:
Do you follow a particular diet? Vegetarian diet with cheese, eggs, milk included

What are your food likes and dislikes? Likes: Beans, pasta, vegetables and fruits, nuts
Dislikes: Seafood
Do you have any especially strong cravings? Sweets

How often do you eat fast food? Twice a month, usually when we have an evening
family counseling scheduled.
How often do you eat at restaurants? Once a month as a date night

Do you have adequate financial resources to Yes


prepare your food?
How do you obtain, store, and prepare food? Bi-monthly grocery shopping. Cook daily meals
and freeze leftovers
Do you eat alone or with another family Eat with family members: son and husband
member/person?
Do you consume any food supplements? Multi-vitamins, flaxseed Omega 3 supplement,
Vitamin D
In the past 12 months have you:
Experienced any changes in weight? Yes

Had a change in your appetite? No

Had a change in your diet? No


COMPREHENSIVE HISTORY AND PHYSICAL 10

Experienced nausea, vomiting, or diarrhea from No


your diet?
Changed your diet because of difficulty in feeding No
yourself, eating, chewing, or swallowing?

Food intake history (24 hour diet recall) You can add rows to this table if you need to by right-clicking
on the bottom row and selecting insert rows below:
Time Food/drink Amount Method of Eating Location
Preparation
0700 Black coffee/ 12 oz/ 8oz Home Kitchen
water
Eggs/ wheat toast 1
0900 Cheese Danish 1 Store bought Work site meeting
1200 Mediterranean 1/16 oz. water Paneras bread Work site
Veggie sandwich
Potato chip
Oatmeal raisin
cookie
Water
1900 Veggie salad with 16 oz water Chipolte Chipolte
beans
Water
2000 Water 8 oz home

Health maintenance (must address sleep, exercise, stress management):


Sleep pattern: 7- 8 hours nightly, uninterrupted
Exercise: 10000-20000 Fitbit steps daily
Long morning walks except on
Wednesday and Thursday
Stress management: Exercise
Prayer
Family therapy

Review of systems (make sure to include all pertinent positives/negatives) Remember that the review
of systems is ONLY subjective information that is, ONLY the history that the patient gives you, NOT
your physical examination. ALL exam findings go below, in the physical exam. Please review table 3-2
on p. 70-71 of your text:
General:
Patient states I am happy, healthy, and have increased energy level since starting regular exercise.

Skin:
Patient states, I am outside for approximately 2 hours every day. She does not use sunscreen. She
uses a hat and sunglasses.

Hair:
COMPREHENSIVE HISTORY AND PHYSICAL 11

Patient states, she uses wash-in hair color every 3 months.

Nails:
Patient states, she does not use nail polish or false nails.

Eyes:
Patient states, I have 20/20 vision in both eyes. I check it at work once a year. She routinely uses
sunglasses and protective eyewear when involved with household projects.

Ears:
Patient stated, she cleans her ears with Qtip swabs.
scant amount of cerumen on swab
one pierced hole in each ear
does not use ear protection when mowing the lawn

Nose and sinuses:


Patient states, no seasonal allergies and gets a cold once or twice a year. Husband says I snore.

Mouth:
Patient states, no mouth sores, lesions and has an overbite and has all 32 teeth. Dental Habits: once a
day brushing and flossing and mouth rinse. I am getting ready to have Invisalign applied to correct the
overbite.

Throat and neck:


Patient stated, I have a continual sore throat for which I take Alka-Seltzer calcium carbonate. My
primary care physician has suggested my sore throat may stem from acid reflux.

Breasts and axilla:


Patient stated, discontinued breast feeding two months ago. Perform self-breast examination every two
months. Scheduled 3-D mammogram and enrolled in the risk assessment program at Anne Arundel
Medical Center for breast cancer because of familial history.

Respiratory:
Patient states no shortness of breath with normal daily activities. Last date of xray and PPD: unknown

Cardiac:
Patient states no issues.

Peripheral vasculature:
Patient states no varicose veins or bruising.

Gastrointestinal:
Patient states, Primary Medical Physician suggested silent gastroesophageal reflux disease (GERD) as
COMPREHENSIVE HISTORY AND PHYSICAL 12

evidenced by continual sore throat, further testing to be determined by gastroenterologist. I have a visit
with a gastroenterologist on May 19th for follow-up. She never had a colonoscopy.

Urinary:
Patient states no trouble voiding.

Musculoskeletal:
Patient states no concerns.

Neurological:
Patient states no complaints.

Psychological:
Patient stated:
increased stress due to life changes,
toddler under the age of two
special needs brother who requires supervision and direction in lifestyle choices

Male or female reproductive:

Last Menstrual Period was 4/23/17


monthly
5 days duration
Number of pregnancy 2 with one live birth.
Vaginal delivery with vacuum assist x3.

OK to defer nutrition, as this is addressed in depth elsewhere


Endocrine:
Patient states inability to lose weight for the past two years, since the birth of her son.

Lymph nodes:
Patient states no concerns.

Hematological:
Patient states no concerns. Her blood type is O+.

Physical examination may defer breasts/genitalia/anus/rectum/prostate if appropriate. Remember


that in this section you will discuss ONLY exam findings no subjective information. All subjective
information goes in the review of systems. Please follow the exam guidelines on p. 1035-:
Constitutional/general survey:

Clean
well groomed
dressed appropriately
COMPREHENSIVE HISTORY AND PHYSICAL 13

strong posture
relaxed face

Measurements:

Height: 65
Weight: 189.6 lbs.
Temperature 98.7
Pulse: 62
Respirations: 16
BP right arm: 98/72
BP left arm: 101/74

Skin:

Warm
Dry
Firm
Intact
No blemish
No moles
No rash
No discoloration
Turgor: elastic

Head and face:

The head is round and symmetrical


The skull is smooth, no bumps or depression noted.
The scalp is clean, shiny, no dandruff.
No lumps or nodules noted.
Her face is oval, symmetrical, no swelling, contusions or blemishes.
The temporomandibular joint opens and closes without pain or clicking.

Eyes:

Clear
White, evenly proportionate on face,
No drainage
No redness
Visual acuity 20/20, visual fields by confrontation intact, no papilledema
Color vision: intact able to identify colors correctly
III, IV, VI: Extraocular muscles intact
Six Cardinal fields of gaze intact, no nystagmus noted
COMPREHENSIVE HISTORY AND PHYSICAL 14

Ears:

Intact
No swelling
No drainage
No pain
Scant amount of cerumen in both ears.

Nose and sinuses:

The nose is symmetrically located middle of the face.


The nose is free of drainage, inflammation, cysts or lesions.
Each nostril is patent.
The sinuses are intact no swelling noted.
The patient did not experience pain during palpation of the sinuses.

Mouth and throat:

The breath is fresh.


The lips and membranes are pink, moist.
The tongue and buccal mucosa are pink, smooth, moist and no inflammation or sores noted.
The tongue is midline and moves freely.
The gums are pale red, intact, no swelling and no ulcerations.
Teeth are aligned with an overbite
No missing teeth and free of caries.
Throat is pink, moist free of swelling, lesions or ulcerations.
Uvula is midline.
The tonsils are present, grade +2.
The gag reflex is present

Neck:

The neck muscles are symmetrical


Non-bulging
No lesions
Spasm free
Head is centrally located
A full range of motion was performed and no discomfort noted
Trachea is midline, no lesions or masses noted.
Carotid arteries are palpable
No bruits heard on auscultation.
Thyroid moves when swallowing.
No swelling, tenderness or masses noted.
No bruits heard
Lymph nodes:
no swelling
COMPREHENSIVE HISTORY AND PHYSICAL 15

inflammation
masses noted

Upper extremities:
Nailbed:
Pink
smooth
slightly rounded
consistent thickness without splitting or damage

Nailbase: firm on palpation

Capillary Refill: is less than 3 seconds


Muscle Size: Hands/Arms/Shoulder:
Well-built equally developed muscles
No atrophy or deformities noted
No involuntary muscle movement noted

Muscle Tone: Smooth and firm

Fingers/Wrist/Elbow/Shoulder Joints:
External joint felt smooth, firm and strong.
The area encompassing the joint is free:
From swelling
Soreness
Pain
Warmth
Lumps
Joints move freely.
Bilateral fingers/wrist/elbow/shoulder strength is 5/5
Radial & Brachial pulses are palpable (+3), bilaterally

Back, posterior, lateral thorax:

Anterior thorax:
Shape: A/P diameter/transverse diameter =1:2,
Superficial Veins: not present
Coastal Angle: <90 degrees
Angle of Ribs: 45 degrees with sternum
Intercostal Spaces: Negative for retractions
Muscle of Respiration: No accessory muscles used
Respiratory Rate: 16 breaths per minute
Sputum: None
Thoracic Expansion: 3 cm
Tactile Fremitus: Present
COMPREHENSIVE HISTORY AND PHYSICAL 16

Percussion: Resonant
Auscultation: Muffled voice sounds

Heart (note that the exam is divided between p. 1039-1040. Include all info in this section):
Auscultation
Aortic +S2
Pulmonic + S2
Tricuspid + S1
Mitral area + S1
Erbs point No weakness in arms or shoulders noted

Pulsation Negative for all cardiac landmarks


Aortic, Pulmonic, Tricuspid, Mitral, negative for thrills and heaves.
Apical pulse is 64

Breasts:
Deferred

Jugular veins:
No distention note

Abdomen/Gastrointestinal:
Abdomen is:
Symmetrical
Rounded
Pink
No masses
No scars

Rectus Abdominis muscle is even


Respiratory movement of the abdomen is consistent and uniform.
Umbilicus is beneath the abdominal surface

Bowel sounds are:


Normoactive
No buits
No venous hum
No friction rub heard

Percussion
Abdomen: Tympany
Spleen: unable to detect
Stomach: Tympany
Bladder: unable to detect

Palpation
COMPREHENSIVE HISTORY AND PHYSICAL 17

Abdomen:
Smooth
Soft
Nontender
No muscle guarding
Liver: not palpable
Spleen: Not palpable
Bladder: Not palpable
Kidney: not palpable
Deep Palpation
No abnormal masses, bulges or swelling.

Inguinal area:
Deferred

Lower extremities:
Pink color, capillary refill less than 3 second, free from edema, ulceration, hair, varicose veins or masses
and ulcers.
Skin was warm to touch, smooth and elastic.
Popliteal, dorsalis pedis and posterior tibial pulses are palpable and strong.
Legs & Feet
Muscle size: Equal in size, bilaterally, and no involuntary muscle movement noted
Muscle tone: smooth, firm
Hip, Knees, Ankles, Feet
External Joint: smooth, and firm
The area encompassing the joint is free from swelling, soreness, pain, warm and lumps. Joints move
freely.
Full active range of motion performed and muscle strength is 5/5.
Position sense: able to perform without any difficulty
Negative for clonus

Neurological system (note that the exam is divided between p. 1036 and two sections on p. 1041.
Include all info in this section):
MENTAL STATUS
Physical Appearance and Behavior:
Posture and Movements: Sitting erect, no deficits noted.
Dress, grooming and personal hygiene: casual clothes, clean, well-groomed
Facial expression: smiling, relaxed, calm
Affect: appropriate, maintains eye contact
Communication:
Clear
Easy flowing speech
Follows directions
COMPREHENSIVE HISTORY AND PHYSICAL 18

Level of Consciousness:
Awake
Alert
Oriented to person, place, time
GCS = 15
Cognitive abilities and mentation:
Attention: focused, task oriented, clear communications, performed subtractions by 3 starting
at 100
Memory: Intact short and long term
Judgment: Intact
Insight: intact, appropriate and accurate
Spatial perception: Intact
Calculation: Intact
Abstract reasoning: Intact
Thought process and content: Rational and sound
Suicide Ideation: Denies
SENSORY
Light touch:
Face: equal, intact bilaterally
Hands: equal, intact bilaterally
Lower Arms: equal, intact bilaterally
Abdomen: equal, intact bilaterally
Feet: equal, intact bilaterally
Legs: equal, intact bilaterally

Superficial pain
Face: dull, equal bilaterally
Hands: dull, equal bilaterally
Lower arms: dull, equal bilaterally
Abdomen: dull, equal bilaterally
Feet: dull, equal bilaterally
Legs: dull, equal bilaterally

Two-point discrimination:
Tongue: Intact, 3 mm
Lips: Intact, 3mm
Fingers: Intact, 5 mm
Dorsum of hand: Intact, 14 mm
Torso: Intact, 10 mm
Feet: Intact, 16 mm
Proprioceptive sensation:
Motion and position: equal, intact bilaterally
Vibration sense:
Fingers: equal, intact
Toes: equal, intact
COMPREHENSIVE HISTORY AND PHYSICAL 19

Cortical sensation:
Stereognosis: two-point discrimination
Graphesthesia: two-point discrimination
Extinction: Intact bilaterally
Cerebellar Functions
Finger to nose: Intact, bilaterally
Rapid alternating movements: able to smoothly run heel down shin, intact bilaterally,
Reflexes
Biceps: contraction of muscle and elbow flexion are intact, bilaterally
Triceps: contraction of muscle and arm extension intact, bilaterally
Brachioradialis: flexion and supination of forearm intact, bilaterally
Patellar: contraction of quadriceps muscle and leg extension intact, bilaterally
Achilles: contraction of calf muscles and planter flexion intact, bilaterally

Plantar Reflex: intact, bilaterally


Babinski Reflex: absent

Genitalia/anus/rectum/prostate:
Deferred

Nursing diagnosis #1 (please review p. 8-10 of your text. There is a complete list of 2012-2014 NANDA
nursing diagnoses in the resources -> course materials):
Risk for impaired body image

Patient goal r/t nursing diagnosis #1 (make sure this is something MEASUREABLE how will you/they
know if theyve been successful? Within what timeframe?):
Patient will lose ten pounds within 3 months

Nursing intervention r/t patient goal #1 (what will you do to help/support them?):
I will have patient come to the office for a weight check once a month.

Nursing diagnosis #2 (please review p. 8-10 of your text. There is a complete list of 2012-2014 NANDA
nursing diagnoses in the resources -> course materials):
Risk for dysfunctional gastrointestinal motility

Patient goal r/t nursing diagnosis #2 (make sure this is something MEASUREABLE how will you/they
know if theyve been successful? Within what timeframe?):
Patient will follow-up with specialist within 2 months.
COMPREHENSIVE HISTORY AND PHYSICAL 20

Nursing intervention r/t patient goal #2 (what will you do to help/support them?):
Patient will follow-up in PMD office to see if symptoms of GERD have decreased as evidenced by no sore
throat for over one week after implementing plan of care by the specialist. Patient will ask
gastroenterologist to send PMD the report of her visit. Patient can schedule a follow-up appointment
or call in or email the results of her