Patient history

Personal data:-
Name:- Kefyalew Arage
Age:-60
Sex:-M
Address:-Mojo
Physician:-Dr.Diriba
Chief Complaint:-
Back pain
Dry Cough
Loss of appetite
Pain in extremities while moving
Difficulties in seeing with left eye
Fatigue
Insomonia(loss of sleeping)
Head ache
Dizziness
Decreased coordination
Weakness
Urine Urgency
Loss of Balance
Social Status:- Occupation:-
Family:-Had 1, wife and 7 childrens
Daily Function:-
Medical History:-
Family illness:- No hx of family illness
Prior Illness:-Hypertension,Osteo Arthritis(OA),Glaucoma
Present Illness:-Newly Diagnosed with Type II Diebetus Mellitus
+SCAP(severe community acquired pneumonia.)
Review of Systems:-
Skin:Light
Head:-Head symmetrically round, hard, and smooth without lesions or bumps. Face
oval, smooth, and symmetrical. Temporal artery elastic and nontender.
Temporomandibular joint palpated with full range of motion without tendernes s.
Eye:-Acuity by Snellen chart R.E. 20/20, L.E. 10/20. Visual fields full by
confrontation. Extraocular movements smooth and symmetric with no nystagmus.
Evelids in normal position with no abnormal widening or ptosis. No redness,
discharge, or crusting noted on lid margins. Conjunctiva and sclera appear moist and
smooth. Sclera white with no lesions or redness. No swelling or redness over
lacrimal gland. Cornea is transparent, smooth, and moist with Right opacities, seen
some opacities on the left eye, Right lens is free of opacities. Irises are round, flat,
and evenly colored. Pupils are not equal in size and Right Eye was reactive to light
and accommodation. Pupils converge evenly.
Ear:-Ears are equal in size bilaterally. Auricles are aligned with the corner of each
eye. Skin smooth, no lumps, lesions, nodules. No discharge. Nontender on
palpation. Small amount of moist yellow cerumen in external canal. Whisper test :
patient repeats 2 syllable word.
Nose,Mouth,Throat:-Lips pink, smooth, and moist without lesions. Buccal mucosa
pink, moist, and without exudates. Stensen/s ducts visible with no redness or
swelling. white to yellowish teeth present. Gums pink without redness or swelling.
Protrudes geographic tongue in midline with no tremors. Equal bilateral strength in
tongue. Ventral surface of tongue smooth and shiny pink with small visible veins
present. Frenulum in midline. Soft palate smooth and pink. Tonsillar pillars pink
and symmetric.
Nose somewhat large but smooth and symmetric. Some lesions seen on the nose,
Able to sniff through each nostril. Nasal septum slightly deviated to the left, but does
not obstruct airflow. Inferior and middle turbinates dark pink, moist, and free of
lesions. No purulent drainage noted. Frontal and maxillary sinuses are nontender to
palpation and percussion.
Neck symmetric with centered head position and no bulging masses. C7 is visible
and palpable with neck flexion. Has smooth, controlled, full range of motion of
neck. Thyroid gland nonvisible but palpable when swallowing.
Trachea in midline. Lymph nodes nonpalpable.
Chest and Back:-No abnormal curvature of spine. Full range of motion, no muscle
spasm But there is some tenderness on back and feels pain while deeply touched.
Axillary lymph nodes nor enlarged.
Cardio Vascular:-Point of maximal impact (or: impulse) (PMI) 5th intercostal space
in mid-clavicular line (MCL), not visible. No abnormal heaves or lifts. No thrill.
Regular rate and rhythm. (RRR) 1 st and 2nd sounds normal intensity (2nd sound
physiologically split). No extra sounds or murmurs.
Lymphatic System:-Known Hypertensive patient on Enalapril 10mg PO Daily
Urinary Tract:-urgent urination
Genitalia:-Penis without lesions. No urethral discharge. Testes normal size without
masses or tenderness. No scrotal masses. No hernia.
Rectal:-No external lesions. Good sphincter tone. No tenderness or masses, firm,
without tenderness or nodules. Brown stool.
Locomotor:-Checked the patient while he moves forward ,backward and upward ,
there is some limitations in freely walking and there are some extent pains on back
and legs.
Nervous:-Head ache
Dizziness
Decreased coordination
Weakness
Loss of Balance Have seen
Extremities:-No asymmetry or muscle atrophy. Some linitations on Full range of
motion (ROM) of all joints.
Normal skin temperature. No edema, or superficial varicosities.
Inguinal lymph nodes not enlarged.
All distal pulses (or: femoral, popliteal, PT, and DP pulses) intact, full, and equal; no
bruits over femoral artery.There is some limitations of moving while he walks.
Phsychological state:-Fatigue,Insomonia(loss of sleeping) Reduce mental or mental
performance capablity was seen
Stimulantia:- No use of Tobacco and Drugs
Medications:- Ceftriaxone 1gram IV BID
Azithromycin 500mg Po DAILY for 3 days
Metformin 500mg PO BID
Meloxican 15mg PO DAILY
Tlmolol 0.5%eye drop apply BID
Enalapril 10mg PO DAILY
RBS QID(EVERY 6 HOURLY)
Vital Sign:-
Bp:-100/70 mmHg, PR:-…….RBS:-254g/dl, HgbAlc:-7.7%, Spo2:-……..Temp…