Patient: A.N.

Subjective
 CHIEF COMPLAINT(s) REASON FOR VISIT:
o Check up

 HISTORY OF PRESENT ILLNESS:
o 68-year-old female patient is here for a check up. The patient came in
with her daughter in law who stated that the patient is urinating on
herself. The urination is very constant and she no longer has any
control of it. The daughter in law stated that this has been going on
for the past 2 months. The urination is without pain. The patient is
also feeling very weak, and does not feel like being active at all. The
daughter in law also stated that the patient is also having trouble
walking on her own because of lower back pain and muscle pain;
therefore, she needs help walking. The patient is feeling dizzy when
she is on her feet and she also has shortness of breath but no chest
pain.

 PAST MEDICAL HISTORY
o Adult medical conditions: Hypertension, diagnosed 2004, DM
diagnosed in 1992.
o Major childhood illnesses: rubella, chicken pox.
o Current medication:
 Egocalciferol 50,000 units once every week
 Coreg (carvedilol) – 12.5mg, 2 times a day orally
 Metformin (Glucophage) – 500mg, 3 times a day orally
 Ditropan (oxubutynin) – 15mg, 2 times a day orally
 Enalapril (vasotec) – 10mg, 1 each, once day orally
 Simvastatin (Zocor) – 40 mg, 1 each, once a day orally
 Aspirin (ecotrin adult low strength – 325mg once a day orally
 Furosemide- 20 mg , 1 each, once every other day
 Digoxin- 125mcg, 1 each once a day orally
 Fosamax- 70mg, 1 each, once a week orally
o Surgical procedures: n/a
o Injuries: Broken leg in 2003, sprained her ankle in 2006.
o Hospitalization: patient has hospitalized in 2006 because she felt
while walking (sprained her ankle).
o Immunizations: DTP, MMR, Hepatitis B, Influenza
o Allergies: penicillin

 FAMILY HISTORY:
o Father: deceased, unknow
o Mother: deceased, unknown
o Siblings: Brother; 58 alive and well. Sister; 65 alive and well.
Patient: A.N.

No history of cancer, alcoholism, or known genetic illness.

 SOCIAL HISTORY
o Living arrangements: with son and daughter in law
o Residence: resides in an apartment
o Sexual history: N/A
o Occupation: unemployed
o Environmental exposures: no identified harmful exposures
o No tobacco, alcohol, or other drug use
o Diet and exercise: patient maintains a good diet and gets moderate
exercise.
o Education: some middle school

 REVIEW OF SYSTEMS:
o GENERAL PREVIEW:
 Patient denies Weight changes and appetite changes. Patient
complains of unusual weakness. Patient denies any bleeding,
recent trauma, infections, chills, or fever.
o HEENT:
 Patient denies Headaches, Blurry vision, Changes in visual
acuity, Nasal congestion/ discharge, Sinus infections, Epistaxis,
Mouth sores, Loss or change of taste or dry mouth.
o NECK:
 Patient denies neck pain, swellings or stiffness.
o LUNGS:
 Patient denies productive or non-productive coughs, wheezing.
 Patient complains of shortness of breath.
o CARDIOVASCULAR:
 Patient denies dyspnea on exertion, orthopnea, PND or
swelling of the lower extremities. Patient also denies
palpitations or rapid heart rate, chest pain, syncope,
intermittent claudication.
 Patient complains on dizziness
o GASTROINTESTINAL:
 Patient denies nausea/vomiting, hematemesis, dysphagia,
abdominal pain, and hematochezia. Patient also denies melena,
diarrhea, constipation, alcoholic stools, and flatulence.
o GENITOURINARY:
 Patient denies any recent dysuria, urine hesitancy, urine flow
being slow, urine retention, nocturia, polyuria, or incontinence.
 Patient complains of urine frequency, urine urgency, nocturia,
polyuria, and incontinence.


Patient: A.N.
o MUSCULOSKELETAL:
 Patient complains of arthralgia, joint stiffness, back pain,
muscle cramps, muscle weakness, and myalgia.
o SKIN:
 Patient denies any rashes, lesions, anhidrosis, bruising or
pruritus.
o ENDOCRINE:
 Patient complains of polyuria and weakness.
 Patient denies any polydipsia, polyphagia, weight loss, and any
history of heat or cold intolerance.
o NEURO:
 Patient complains of having migraines and tension headaches.
 Patient denies blurring vision or changes in visual acuity,
diplopia, and photosensitivity. Patient also denies any memory
loss, disorientation, syncope, dizziness, vertigo, clumsiness,
paresthesias, and loss or change of taste.
 Patient has a history of sleep disturbances, unusual emotional
changes, mood swings or depression.

Objective
 VITAL SIGNS:
o BMI: 30.5
o BP: 118/74
o H: 61.00 IN
o P: 80/MIN
o RR: 16/MIN
o T: 97.4 F
o W: 161LB

 PHYSICAL EXAM
o GENERAL:
 General appearance; can be described as well nourished, well
developed, and in no acute distress.
o LYMPHATIC:
 No abnormal neck, axillary, groin lymph nodes detected.
o HEAD:
 No lesions of oral or nasal mucosa. Tympanic membranes are
intact.
o EYES:
 Acuity 20/20(R); 20/20(L) visual fields. Eyes are aligned; lids,
conjunctivae and sclera are normal; pupils are 3mm and equal;
normal response to light; extraocular movements (EOM) are
intact; Fundi; sharp disc margin; no hemorrhage, no lesions, no
discharge or other abnormalities.
Patient: A.N.


o EARS:
 Outer ear without lesions, normal acuity, tympanic canals
normal; tympanic membrane with normal light reflex, no
erythema or bulge.
o NOSE/ SINUSES:
 Nasal mucosa is normal, nasal septum is midline, no
tenderness over maxillary or frontal sinuses.
o MOUTH & PHARYNX
 Normal lips, tongue, gums and healthy teeth; pharynx is
normal. Tonsils are normal.
o NECK:
 Lymph nodes are normal. Neck tissue exam demonstrates no
masses, symmetrical. Trachea is midline. Thyroid is palpable
and normal.
o CHEST/ LUNGS:
 Normal to inspection; respiratory effort symmetric without use
of accessory muscles.
 Normal to inspection. Lung auscultation shows no wheezing,
and equal breath sounds.
 Breath sounds are normal with no extra sounds.
o CARDIAC:
 Heart auscultation shows regular rates and rhythms, there are
no murmurs, gallop or rub. Normal heart sounds.

o VASCULAR:
 2+ carotid pulse bilaterally- no bruits
 Aortic pulsation normal, no bruits over aorta, femoral or renal
arteries
 Pulses
Radial Femoral Popliteal D. Pedis P. Tib
R 2+ 2+ 2+ 2+ 2+
L 2+ 2+ 2+ 2+ 2+

No lower extremity edema, no varicosities.

o ABDOMEN:
 Normal bowel sounds
 No mass or tenderness found.
 LIVER/SPLEEN: no hepatomegaly or splenomegaly.
 Hernia checking discovers no bulging or weakness in
abdominal wall.



Patient: A.N.
o MUSCULOSKELETAL:
 Full range of motion and normal appearance of all joints of
upper and lower extremities. No major bone, joint, tendon, or
muscle changes.
o NEUROLOGICAL:
 Mental status normal – 30/30
 Patient is alert and oriented.
 Cranial nerves II – XII are intact
 Motor strength 5/5 throughout and no increased tone
 Sensory function normal to light touch, vibration and joint
position sense
 Coordination normal
 Biceps, brachioradialis, triceps, knee, ankle reflexes 2+
bilaterally
 Babinski negative, no clonus, gait normal, Romberg negative,
no pronator drift
o GENITALIA:
 EXAM NOT DONE
o RECTAL EXAM:
 N/A
o PSYCHIATRIC:
 Insight and judgment appear both to be intact and appropriate.
 Mood and affect are described as normal mood and full affect.
o SKIN:
 No rashes or lesions.

Assessment
 Urinary incontinence
 Lumbar pain
 Myalgia/ Weakness
 Depression
 Hypertension is well controlled on medication.

Plan
 Urinary incontinence: continue patient on:
o Oxybutynin 15mg, 2 times a day orally
 Have patient continue all her current medications
o Egocalciferol 50,000 units once every week
o Coreg (carvedilol) – 12.5mg, 2 times a day orally
o Metformin (Glucophage) – 500mg, 3 times a day orally
o Ditropan (oxubutynin) – 15mg, 2 times a day orally
o Enalapril (vasotec) – 10mg, 1 each, once day orally
o Simvastatin (Zocor) – 40 mg, 1 each, once a day orally
o Aspirin (ecotrin adult low strength – 325mg once a day orally
o Furosemide- 20 mg , 1 each, once every other day
Patient: A.N.
o Digoxin- 125mcg, 1 each once a day orally
o Fosamax- 70mg, 1 each, once a week orally
 Lumbar pain and Myalgia:
o CT Scan of lower back
o Start patient on Ibuprofen 800 mg q 6-8 h a day.
 Discontinue Furosemide- 20 mg , 1 each, once every other day
 Depression: refer to psych

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