Medical History and Physical Exam
Client Name: Chuck Ellis
Age: 60
Sex: Male Race: African American
Medical history: Arthritis; COPD (mild) no recent exacerbations; he inhaled some noxious gas at a former place of employment; underwent pulmonary rehabilitation and reports no problems since then.The Ameican Lung Association (2019) says a person “with a chronic lung disease, like chronic obstructive pulmonary disease (COPD) or pulmonary fibrosis, there is hope for rebuilding strength and enjoying a more full and active life through pulmonary rehabilitation. These programs are designed to improve lung function, reduce symptom severity and improve quality of life” (American Lung Association, 2019).
Family History: He does not know because he was adopted by his parents. Patient says he was not interested in knowing his birth parents. He was educated that about how he could obtain his adoption records without having contact with his birth parents by going to his local health department with the information about his birth such as date and location. If that is unsuccessful he could also petitioin the court for medical history information. According to Adoption.org (2019), closed adoptions will have sealed records, but a judge can open them. “Judges do not like to open sealed records except under extraordinary circumstances. Usually, it would mean that you would need to be suffering from some medical ailments that require your family’s medical history to help with your diagnosis or treatment” (Adopton. org, 2019).
Social history: Reports no smoking, illicit drug use; occassional alcohol consumption
(> 2 beers/ week) While some studies have shown that low amounts of alcohol may have a cardioprotective effect from alcohol. However, Jackson, et al. (2015) of the American Journal of Public Health, say, “Some data have suggested that Blacks (men, in particular) do not experience the apparent cardioprotective effect of alcohol. . . . Low to moderate alcohol consumption [showed] increased risk of hypertension among 512 Black men in the CARDIA study” (Jackson, et al., 2015, p. 534). Jackson, et al. (2015) also point out, “The rapid metabolism of alcohol among Blacks resulting from potential genetic differences could reduce cardiovascular benefits, yet we found a suggestion of benefit for light consumption among Black women, but not among Black men” (Jackson, et al., 2015, p. 541).
Height : 6’2” Weight: 185 lbs. BMI: 23.7
General health survey: Well-developed, thin but has muscles across chest and upper arms; has lanky build; vegetarian diet with occassional fish (pescatarian diet). Pescatarian diets are basically vegetarian diets only practitioners it fish and seafood as well. DerSarkissian (2019) of Web MD says, “A diet that puts an emphasis on plant-based foods, fish, and seafood may provide health benefits. Fish, like meat, is a good source of protein. Yet, unlike red meat, it's low in saturated fat and often rich in healthy omega-3 fatty acids. Studies show that eating less red meat, or none at all, lowers your chances of getting heart disease and high blood pressure. At the same time, two servings of fish a week may help your heart” (DerSarkissian, 2019). Mr. Ellis’ healthy diet may explain his lean body structure.
No acute distress. Alert to person, place and time. Pain rate: 1/10 because of arthritis in shoulders.
Integumentary: No rashes or lesions; hair evenly distributed; no alopecia. Temperature: 98.0 F
HEENT:
Head: round and symmetric, scalp is clear. No bumps or lesions, no pain or tenderness
Face: Eyes are symmetrical; nose is midline. No facial weakness or sagging; Pink-colored nasal mucosa. No swelling or drainage. No pain or tenderness when palpitated
Eyes and ears: Eyes are clear; no cloudiness or watering; Conjunctiva moist and pink,. External ear is brown. Earing intact, tympanic membrane grey; light reflex intact. Landmarks visible, no drainage or bleeding.
Mouth/throat: Pharynx uniform pink no whitish exudate, no tonsils; teeth appear white, gums show no infection; tongue appears normal; uvula appears pink and normal.
Neck: No swelling in lymph nodes nonpalpable, nontender. Thyroid and nodes not palpable. Some stiffness when he move neck to right side
Chest: Nipples appear light brown and normal; no swelling; no discharge;symmetrical
Respiratory: Respiration regular and unlabored. No coughs, clear breath sounds, no rattles or rails sounds. Unable to take very deep breaths. Equal bilaterally. Respiration rate: 18 breath/minute. Lungs clear. Oxygen saturation: 99 %.
Cardiovascular: Apical and radial pulses normal. S1, S2 present and regular, with no adventitious or extra heart sounds. Pulse + 2/4. No bruits. Herat rate: 68 beats/minute. Blood pressure: 128/79 mmHg.
Gastrointestinal: Abdomen round, soft. Positive bowels sounds, nontender, no organomegaly when palpitated. No detected swelling or abnormalities in liver, spleen, bladder, aorta, or inguinal nodes
Vascular: Extremities appear normal; no bruising noted;
Genitourinary: External genital brown, intact, no lesions. No abnormal lumps on scrotum.
Musculoskeletal: Full range of motion with tenderness in right shoulder. Muscle Strength 5/5 and equal bilaterally, no tremors. No joint deformities detected but says his shoulders have been bothering him more lately than they used to. C/O mild pain, stiffness
Neurological: Intact cranial nerves and sensation. Coordinated movements. Sensory intact, no numbness, paralysis, or paresthesia. Steady gait. Sense of touch intact. Reflexes intact;
Skin: Warm to touch; some dryness noted on hands (he says because of his work); no unusual moles or lesions; nails appear normal; some superficial cuts on hands (also because of work)
References
Adopton. org. (2019). Can I Get My Medical History in a Closed Adoption? Retrieved from Adoption.org: https://adoption.org/can-get-m...
American Lung Association. (2019). The Basics of Pulmonary Rehabilitation. Retrieved from American Lung Association: https://www.lung.org/lung-heal...
DerSarkissian, C. (2019, July 18). What is Pescatarian? Retrieved from Web MD: https://www.webmd.com/diet/pes...
Jackson, C. L., Hu, F. B., Kawachi, I., Williams, D. R., Mukamal, K. J., & Rimm, E. B. (2015). Black-White differences in the relationship between alcohol drinking patterns and mortality among US men and women. American Journal of Public Health, 105(3), S534-43. Retrieved from https://www.ncbi.nlm.nih.gov/p...
