Comprehensive Physical Examination Essay Assignment

SUBJECTIVE DATA:

Chief Complaint (CC): “I have visited the clinic for a comprehensive physical examination.”

History of Present Illness (HPI): The client, K. J., a 44yo female, visits the clinic for a complete physical examination. The client complains of feeling fatigued and proptosis. She further reports a history of hyperlipidemia, are her TSH levels during today’s visit are elevated. The client is overweight, and her neck is swollen. Comprehensive Physical Examination Essay Assignment

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Medications: Denies current medication

Allergies: Denies known allergies

Past Medical History (PMH): Reports history of hyperlipidemia

Past Surgical History (PSH): Reports a history of surgery during childbirth.

Sexual/Reproductive History: The client has three children. She is sexually active and uses daily pills as a contraceptive method. Her last monthly period was June 17, 2023. She has a regular menstruation cycle of 28 days.

Personal/Social History: The client was born and raised in Boston. She has a master’s degree in accounting. She works in the city as a banker. The client lives in a four-bedroomed bungalow with her husband and their three children. She is a dedicated Christian and participates in all church activities actively. She does not engage in physical activities. She likes high-energy foods. Comprehensive Physical Examination Essay Assignment

Immunization History: The client received the flu vaccine on March 23, 2023.

Significant Family History: All her grandparents are deceased. Her parents are alive. Her father is struggling with hypertension, Type 2 DM, and arthritis at 87 years. Her mother is 77yo with a history of breast cancer and hyperlipidemia. Her elderly sister is 49, with T2DM, diagnosed five years ago. His younger brother is 37yo with GAD, diagnosed two years ago. All her three children, ages 13, 10, and 4 years are alive with no current medical diagnoses.

Review of Systems:

General: Reports current weight gain and feeling fatigued.

HEENT: Denies deformities to the scalp. Denies visual loss. Denies hearing loss. Denies runny nose. Denies sore throat.

            Respiratory: Denies edema.

            Cardiovascular/Peripheral Vascular: Denies coughing or sputum production

            Psychiatric: Denies suicidal thoughts or anxiety.

            Neurological: Denies weakness

            Lymphatic: Denies swollen lymph nodes Comprehensive Physical Examination Essay Assignment

OBJECTIVE DATA:

Physical Exam:

Vital signs: RR 18; W 189.2lbs; H; 5 “9”; T: 37°C; BMI; 27.6; Bp 135/80 mm Hg; and pulse oximetry 97%

General: The client is smartly dressed and well-groomed. She appears to be in good health. She sits in an upright posture and smiles throughout the interview. The client demonstrates perfect motor activity. Her effect and judgment are good.

HEENT: No scars seen on the head. A protrusion was detected in one eye. No mucus was seen from her nose. Her external ears are well-developed. No swollen or red tonsils were detected.

Neck: Masses or swellings seen on her neck

Respiratory: Cracking sounds were heard

Cardiology: Regular heart rate and rhythm identified.

Lymphatics: No swollen lymph nodes detected on her armpits.  

Psychiatric: No anxiety or mood swings were demonstrated during the clinical interview.

Diagnostics/Labs

ASSESSMENT:

Hyperlipidemia – Primary diagnosis

            The client’s most likely diagnosis is hyperlipidemia, characterized by elevated serum cholesterol and triglyceride. The client qualifies for this diagnosis since she has a history of hyperlipidemia. Studies show that hyperlipidemia is a genetic condition, and it is passed from parents to offspring due to LDL receptor gene mutation (Stewart et al., 2020). Therefore, parental risk predisposes the client to hyperlipidemia since her mother has been diagnosed with this condition. Comprehensive Physical Examination Essay Assignment

Hypothyroidism: The client also has hypothyroidism since her TSH levels were elevated during today’s clinic visit. According to Wilson et al. (2021), the anterior pituitary loss of negative inhibition leads to an elevation in TSH levels in individuals with hypothyroidism. Other symptoms of hypothyroidism include tiredness; sensitivity to cold or heat; weight gain; slow movements and thoughts; constipation; weakness; and muscle aches or cramps. The client reported weight gain and excess fatigue, qualifying for this diagnosis.

Overweight: The client can also be diagnosed as overweight since she reports a history of being overweight. Additionally, the client’s BMI score during today’s visit was 27.6, indicating she is overweight (Loman & Schuttelaar, 2022). Furthermore, parental history of overweight and obesity predisposes the client to be overweight.

Proptosis: The client’s final diagnosis is proptosis since the client reported its history. It is characterized by the protrusion or bulging of the eyeball from the orbit (Topilow et al., 2020). In adults, this condition is mainly caused by Graves’ disease. It is associated with various clinical manifestations, including eye redness or pain, vision loss, headache, diplopia, and fever. Comprehensive Physical Examination Essay Assignment

References

Loman, L., & Schuttelaar, M. L. (2022). Hand eczema and lifestyle factors in the Dutch general population: evidence for smoking, chronic stress, and obesity. Contact Dermatitis, 86(2), 80-88.

Stewart, J., McCallin, T., Martinez, J., Chacko, S., & Yusuf, S. (2020). Hyperlipidemia. Pediatrics in Review, 41(8), 393–402.

Topilow, N. J., Tran, A. Q., Koo, E. B., & Alabiad, C. R. (2020). Etiologies of Proptosis: A review. Internal Medicine Review, 6(3): 1–7.

Wilson, S. A., Stem, L. A., & Bruehlman, R. D. (2021). Hypothyroidism: diagnosis and treatment. American Family Physician, 103(10), 605-613.

Kali, a 44 year old female is in the office for a complete physical examination. She complains of proptosis and feeling fatigued. Her TSH levels are elevated, she has hyperlipidemia, her neck appears swollen, and is overweight. Comprehensive Physical Examination Essay Assignment

Assignment 1 is a SOAP note. It is due by Day 6 of Week 5. Your case assignment is listed in the Announcements area. Please remember to post your response in a SOAP note format. You will need to make up some of the details for the SOAP if they are not given to you. The template for the SOAP note is located in the Week 5 Resource area. I also encourage all of you to review the SOAP note exemplar to see how to word items.

An important point to remember is that the subjective section is what the patient tells you and the objective section is your exam (what do you see or hear). It is important to not mix this information up. Comprehensive Physical Examination Essay Assignment