HISTORY AND PHYSICAL EXAMINATION FORM

Case Number: 0287

Name: Manuel Co Birthday: 02/14/1952
Address: Age: 69
Tayabas City
Sex: Male
Chief Date Admitted: 04/12/2021
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Complain: Time Admitted 10:32 am
History of Present Illness:
 Diabetes type 2 was diagnosed in 2015. He had symptoms of hyperglycemia for
two years prior to his diagnosis. He had fasting blood glucose levels of 118-127
mg/dl, which were described as "borderline disease." In addition, he had nocturia
episodes in the past that were associated with large pasta meals and Italian
pastries. He was told he needed to lose weight, but no action was taken.
 He presented to the diabetes specialty clinic with recent weight gain, suboptimal
diabetes control, and foot pain. He has been attempting to lose weight and
increase his exercise for the past six months without success. He began taking
gliclazide but discontinued it due to dizziness, which was frequently accompanied
by sweating and a feeling of mild agitation in the late afternoon. In addition, he is
taking atrovastatin (Lipitor) for hypercholesterolemia..
 He had been taking Metformin for the past 6 months but had stopped when he did
not see any positive results.
 He lives with his 48-year-old wife and has two married children. Despite the fact
that both his mother and father had type 2 diabetes, he has little knowledge of
diabetes self-care management.
 According to medical records, his A1C has never been less than 8%, and he has
difficulty maintaining his blood pressure at 130/80 mmHg. He is being treated
with amlodipine, losartan, and clopidogrel.
 He's never had a foot exam as part of his primary care visits, and he's never been
taught about preventive foot care.
Pertinent Past Medical History:
 Mr. Manuel has no accurate record of childhood health records. His medical
records indicated that he had no surgeries or hospitalizations, his immunizations
are up to date and in general, he has been remarkably healthy for many years.
Pertinent Signs and Symptoms on Admission:
 Weight gain
 Suboptimal diabetes control
 Foot pain
Physical Examination:
 Awake and Alert
 Weight: 178 lb
 Height: 5’2
 BMI: 32.6 kg/m2
 Fasting Capillary Glucose: 166 mg/dl

VITAL SIGNS:
BP: lying, right arm - 154/96 mmHg
Right arm - 140/90 mmHg
PR: 88bpm
RR: 20 bpm
Temp: 36.2
SKIN, HAIR, NAILS
Skin: is uniform in color and very dry, with intact skin and no reddened areas noted,
with cherry angiomas in the body, has poor skin turgor.

Hair: clean, thick, greyish color, evenly distributed. There is no signs of infection and
infestation is observed.

Nails: Fingernails are short in length, intact with the epidermis; with capillary refill
of 2-4 secs.

HEAD, NECK
Head: is symmetrically rounded, No nodules or masses upon palpation. Face
appeared smooth and has uniform consistency with wrinkles and with no presence of
nodules or masses.

Neck: is symmetric without masses, head centered and no bulging masses. Lymph
nodes are non-palpable. Trachea in midline. Thyroid non- palpable.

EYES, VISION, EARS

Eyebrows: are symmetrically aligned and showed equal movement when asked to
raise and lower the brows. Hair is evenly distributed. Eyelashes appeared to be
equally distributed and curled slightly outward.

Eyelids: no presence of discharge, no discoloration and lids close symmetrically with

involuntary blinks approximately 15-20 times per mins.

Eyes: 2cm apart without portusion. Bulbar conjunctiva appeared transparent, sclera
appeared white, palpebral conjunctiva appeared shiny, smooth,and pink. No edema or
tearing in lacrimal gland. Cornea is transparent, smooth and shiny, iris are visible. The
client blinks when the cornea touched. Pupils of the eyes are black and equal in size,
iris is flat and rounded, constrict when looking at near object and dilate at far object,
converge when object moved towards the nose. With corrective lenses.

Ears: Auricles without deformity, lumps or lesion. Auricles and mastoid process is
non- tender. Bilateral auditory canals are clear. Tympanic membrane are pearly gray
bilaterally with visible landmarks. Hearing intact with whisper test bilaterally. Webers
test: Vibrations heard equally well in both ears with no lateralization to either side.

NOSE & SINUS

Nose appeared symmetric, straight and uniform in color. There was no
presence of discharge or flaring. When lightly palpated, there were no tenderness and
lesions.

MOUTH, THROAT, NOSE AND SINUSES

Lips are pink, moist, symmetric and have a smooth texture. The client was
able to purse his lips when asked to whistle. Teeth and Gums: no discoloration of the
enamels, no retraction of gums, pinkish in color of gums. Buccal mucosa appeared as
uniformly pink, moist, soft, glistening with elastic texture. Tongue midline when
protruded, no lesions, or masses. No lesions, discolorations, or ulcerations on floor of
the mouth, oral mucosa or gums. Smooth palates are light pink and smooth while the
hard palate has a more irregular texture. Uvula is positioned in the midline of the soft
palate. External structure of nose without deformity, asymmetry, or inflammation.
Nares patent. Turbinates and middle meatus pale pink, without swelling, exudate,
lesions, or bleeding. Nasal septum midline without bleeding, perforation, or deviation.
Frontal and maxillary sinuses non-tender.

THORAX, LUNGS
Skin light brown without scars, pulsations or lesions. Thorax expands evenly
bilaterally without retractions or bulging. Respirations even, unlabored, and regular.
No tenderness, crepitus, or masses. Tactile fremitus equal and symmetric bilaterally.
Vesicular breath sounds heard throughout. No crackles, wheezes, or friction rubs.

BREAST:
Breast (Chest) Breast are symmetric, with no swelling, nodules or ulceration
noted; nipples inverted bilaterally, no discharge, masses and tenderness noted

HEART AND NECK VESSELS:

No pulsations visible. No heaves, lifts, or vibrations. Apical impulse: 5th Inter
coastal Space Left Midclavicular line. Clear, brief heart sounds throughout. S1 S2
present. No S3, S4, gallops, murmurs, or rubs

ABDOMEN:
Abdomen has unblemished skin and is uniform in color. Soft.  Bowel sounds
are in low pitched. No distension and no tenderness.There were symmetric
movements caused associated with clients respiration. Jugular veins are not visible.
Umbilicus in the midline without herniation, swelling, or discoloration. Aortic, renal,
and iliac arteries auscultated without bruit. No venous hums or friction rubs
auscultated over liver or spleen. Tympany percussed throughout. No tenderness or
masses noted with light and deep palpation.

EXTREMITIES:
Upper extremities: Equal and size and symmetrical bilaterally; light brown; warm and
dry to touch without edema, bruising, or lesions. Radial pulses = in rate and 2+
bilaterally. Brachial pulses equal and 2+ bilaterally.

Lower extremities: Legs symmetric. Skin intact, light brown; warm and dry to touch
without edema, bruising, lesions, or increased vascularity. Femoral pulses 2+ and
equal without bruits. Dorsalis pedal and posterior tibial pulses1+ and equal. With foot
pain noted.

GENITALIA:
Fair in complexion, with symmetric size of testis, no masses or bulging noted,
with no discharge or lesion in penis, no rashes or redness noted

ANUS, RECTUM AND PROSTATE:

Anal opening is hairless, moist and closed tightly. No lesion, redness, lumps
and rashes noted on perianal area.

MUSCULOSKELETAL
Posture: Slumped shoulder, uneven weight bearing is evident. Client cannot stand on
heels or toes. Toes point in or out. Client limps and, shuffles. Falling backward easily,
decreased ROM of partial extremities

Cervical, Thoracic, and Lumbar Spine: Lumbar curvature is flattened. Neck pain with
a loss of sensation in the legs, limited Range of Movement, low-back strain, inability
to shrug shoulders against resistance.

Hips: Pain and a decrease in internal hip rotation

NEUROLOGIC
Cranial Nerve examination: CN I through X grossly intact, with asymmetric muscle
contraction or drooping of the shoulder

Motor and Cerebellar examination: Partial extremity weakness, gait is unsteady

Sensory Status Examination: Superficial light and deep touch sensation intact on
arms, hands, fingers, legs, feet, and toes. Stereognosis and graphesthesia intact.