Case 1 Subjective Data

Case 1

Subjective Data

Chief Complaint
(CC)

“I came for my annual physical exam, but do not want to be a burden to my daughter.” 

History of Present Illness (HPI)

At-risk 86-year-old Asian male – who is physically and financially dependent on his daughter, a single mother who has little time or money for her father’s health needs.

PMH

Hypertension (HTN), gastroesophageal reflux disease (GERD), b12 deficiency and chronic prostatitis

PSH

S/P cholecystectomy

Drug Hx

Current Meds: Lisinopril 10mg daily, Prilosec 20mg daily, B12 injections monthly, and Cipro 100mg daily.

Allergies

Family Hx

Review of Systems (ROS)

 General

+ weight loss of 25 lbs over the past year; no recent fatigue, fever, or chills.

Head, Eyes, Ears, Nose & Throat (HEENT)

No changes in vision or hearing, no difficulty chewing or swallowing.

 Neck

No pain or injury

 Respiratory

 CV

GI

GU

no urinary hesitancy or change in urine stream

Integument

multiple bruises on his upper arms and back.

MS/Neuro

+ falls x 2 within the last 6 months; no syncopal episodes or dizziness

Objective Data

 PE

B/P 188/96; Pulse 89; RR 16; Temp 99.0; Ht 5,6; wt 110; BMI 17.8

 General

 HEENT

Atraumatic, normocephalic, PERRLA, EOMI, arcus senilus bilaterally, conjunctiva and sclera clear, nares patent, nasopharynx clear, edentulous.

 Lungs

CTA AP&L

Card

S1S2 without rub or gallop

Abd

benign, normoactive bowel sounds x 4

GU

Ext

no cyanosis, clubbing or edema

Integument

multiple bruises in different stages of healing – on his upper arms and back.

MS

Neuro

No obvious deformities, CN grossly intact II-XII