Hematologic: Denies any anima or blood transfusion. Does not bruise easily. Endocrine: No night sweets or frequent urination. No endocrine problems. Allergic/Immunologic: No history of allergic seasonal rhinitis, asthma or food/drug allergies. Has never been tested for HIV. Physical Exam: Vital signs: Vital signs: B/P 139/89, left arm, sitting, regular cuff; P 88 and regular; T 98.2 orally; RR 16; non-labored; Wt: 275 lbs; Ht: 5’11”; BMI 38 General: A&O x3, Looks healthy except for obesity, posture is straight, no abnormalities in gait. Looks to be well groomed and comfortable. “I do not have as much energy as I used to.” HEENT: Head and facial features Symmetrel. PERRLA, EOMI, Teeth intact and well- kempt, mucosa membranes moist. Neck: Has full ROM without pain. Lymph nodes not swollen. Carotids with no bruit, no JVD. Chest: Chest wall expansion symmetrical. Lungs: Breathing nonlabored , breath sounds clear bilat, no adverse sounds heard. Heart: S1 S2 loud and clear, no murmurs, clicks, or gallops heard. Heart rate regular. Peripheral Vascular: Pulses palpable, +2 bilat pedal and +2 radial. No edema notes. Abdomen: Large, round, obese, bowel sounds present x4, no organomegaly, masses, or rebound tenderness. Genital/Rectal: External genitalia intact, no masses, tenderness, or varicoceles. Musculoskeletal: Symmetric upper and lower extremities, full ROM of all joints. No weakness noted strength at 5/5 all groups. Neurological: Alert and oriented x3, cranial nerves - grossly intact. Brachioradialis, Ⅰ Ⅻ biceps, triceps, quadriceps, and ankle reflexes 2+. Skin: No edema, scars, sores, rashes, or tattoos noted. Small mushroom shaped skin tag in the right axilla area, it is 0.5cm x 0.5cm x 1cm in size, the color of the skin tag is slightly browner than the skin around it, no pain associated with it. © 2014 Laureate Education, Inc. Page 3 of 5
Lab abnormal results: LDL: 165 HDL: 49 Total Cholesterol: 245 Triglycerides: 150 Diagnostics: Lab: CBC, CMP, Lipid profile, TSH, A1C ECG: Normal sinus rhythm Differential Diagnosis (DDx): 1. Stage 1 Hypertension 2. Hyperlipidemia 3. Obesity 4. Cutaneous tag (acrochordon) Diagnosis: 1. According to the new guidelines stage 1 Hypertension: 130-139 mm Hg systolic blood pressure (SBP) or 80-89 mm Hg diastolic blood pressure (DBP) (American Heart Association, 2016). The risk for organ diseases like myocardial infarction, kidney disease, and stroke increase with any stage of hypertension (Huether & McCance, 2017).
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- Summer '15