H & P

 

BIOGRAPHIC DATA

 

Name:  Jason R. Landers         

Address:  Juniper Rd  

Marital Status: Married.

Source:  Reliable.

Reason for seeking care: The patient is a 42-year-old male with a history of chronic migraines who comes to the clinic stating medication are not working any longer.

 

History of present illness: Mr. Landers reports onset of symptoms started four days ago. Patient states he took Maxal 10mg at first onset of headache. Patient continued on taking medications as prescribed, no more than two tables in a 24-hour period. Patient states headache is not allowing him to work. Patient needs to be in a dark place to feel somehow comfortable. Patient states he cannot handle the pain anymore.

 

PAST HEALTH

 

Childhood Illnesses:   Childhood Asthma. Chickenpox at age 8.  All childhood immunizations up to date.

 

Accidents:  Work related accident. digitus medius amputation after manufactory machine partial cut off fingertip.

Chronic illnesses: Migraine headaches began in his early 30’s.

 

Hospitalizations:  Age 25 pneumonia.

 

Obstetric History:  male patient.

 

Last Examinations:  September 2015 migraines. Medication changed from Imetrex to Maxal.

 

Allergies:  NKDA.

 

Current Medications: Zocor 20mg daily, Maxal 10mg  PRN. Albuterol inhaler, Claritin OTC PRN.

 

 

REVIEW OF SYSTEMS- HISTORY

 

General Health:  States that he is in fair health. Patient exercises at least three times a week.

 

Skin:  dry, intact. No open wounds.  Hyperpigmentation of face from frequent sun exposure.  Client does not use sunscreen.  No history of skin cancer, or rash. Nails appear normal.

 

Head:  Severe migraines headache monthly.  No report of syncope, dizziness or vertigo. Previous MRI showed no lesion or acute changes.

 

Eyes:  Wears reading glasses. No blurry and double vision. Pain was located at the left eye and now has travel to the right. 

 

Ears:  No reported hearing loss or difficulty.  No report of ear pain, infection or discharge.

 

Nose:  Occasional clear nasal discharge in spring.  Patient takes OTC for seasonal allergies.

 

Mouth and Throat:  Patient denies toothache, sores or lesions in the mouth.  Self-care: brushes and floss teeth daily. Patient chews tobacco.

 

Neck:  Denies pain, stiffness, limited movement or swelling.

 

Breast: No pain, lumps, rash or discharge.  Patient has never performed self -breast exams.

 

Respiratory:  History of Asthma, acute Bronchitis. Reports SOB, wheezes when he gets a cold/flu. Has a recue inhaler. No chest pain.  No history of smoking or living with a smoker.  Has not been exposed to environmental inhalants.

 

Cardiovascular:  No reported chest pain, palpitations, cyanosis, fatigue, dyspnea or orthopnea.  No history of heart murmur, last cholesterol screen was 250, no report of anemia. 

 

Peripheral Vascular:  No pain numbness of tingling leg edema.

 

Gastrointestinal:  No nausea, vomiting or abdominal pain reported. No GI problems reported. Gastroenteritis in 2015.

 

Urinary:  Nocturia, No history of kidney disease. No other problems reported.

 

Genitalia:  No genital itching, discharge, sores or lesions. 

 

Sexual Health: Sexually active. One partner.

 

Musculoskeletal:  No history of arthritis, no c/o joint pain, stiffness, swelling. Finger deformity from ambulation. No muscular pain or weakness.  Self-care:  exercises three times a week per patient.

 

Neurologic:  No history of seizure disorder, stroke or fainting episodes. Anxiety. Reports no depression. No suicidal thoughts.

 

Hematological:  No history of bleeding disorders, no excessive bruising, no blood transfusions.

 

Endocrine:  Paternal grandfather had diabetes.  No complaints of excessive thirst, urination or hunger.  No other problems reported.

 

FUNCTIONAL ASSESSMENT

 

Self-Concept:  Graduated from high school.  Works as for a golf course maintenance. Lives with his wife.  Believes in God and reads he bible every day, but does not attend to a specific church.

 

Activity-Exercise:  Typical day:  Wakes at 5:00AM, prepares for work, goes to gas station for coffee and a muffin.  Works all day in the outdoors. Eats lunch in the club cafeteria. Eat differently every day but mainly something light such a salad for lunch.  For dinner, he waits for the wife to get home, around 2000 and eats whatever she brings home. Patient enjoy boxing and goes to the gym at least three times a week for an hour.  Patient performs all the ADL independently with no aids.  Hobbies include reading and watching TV, running, playing drums.

 

Sleep-Rest:  Drinks tea at 1900. Goes to bed around 1930 reads the bible.  Bedtime around 2000 sharp. Sleeps about 8-9 hours daily. Wakes up around to 0200 to void. Does not use sleep aids.

 

Nutrition: 24 hour menu recall was as follows.   Breakfast- coffee.  Lunch- collar green and steak and diet coke.  Dinner- 4 slices of pizza.  Snack- popcorn.  No food intolerances.

 

Alcohol/Drug:   Drink only on special events.  Denies use of recreational drugs in the past or present.

 

Interpersonal Relationships:  Describes childhood as “not a normal one”.  Grew up in a divorced household with one siblings.  One close friend.  Visits with daughter is sporadic and describes their relationship as good.

 

Coping and Stress management:  Reports a good relationship with God and asks for help during tough times. He denies any financial difficulties and feels his surroundings are safe and adequate.

 

PERCEPTION OF HEALTH

 

Patient is concern that his migraines is an impediment to work. He is tired of not being able to control them. Patient expresses that his episodes are not frequent but are horrible when he gets it.

MEASUREMENT

 

HGT:  68 inches WT:  175 lbs.

B/P:  115/74 right arm

Temp: 98.7n temporal

Pulse:  72  regular

Respirations:  16  room air, unlabored.

 

General Survey:  Jason is a 42-year old white male, who articulates clearly, ambulates without difficulty.

 

HEAD TO TOE EXAMINATION

 

Skin:  The skin is dry and intact with good skin turgor.  No moles or birthmarks noted.  Nail beds are pink and firm with brisk capillary refill. No nail over right middle finger. Hair is well

 distributed.

 

Head:  Normocephalic, with no scalp lesions or deformities noted.  Face is symmetrical with no drooping of the mouth or eye.

 

Eyes:  Conjunctivae is pink, sclerae white, no lesions or redness noted. No eye drainage. Visual acuity is 20/20 bilaterally. Visual fields are full to confrontation. Pupils are 4 mm and briskly reactive to light. At primary gaze, there is no eye deviation. Patient complaints of right eye pain. Wears reading glasses.

 

Ears:  There are no masses or lesions or tubercles.  There is no pain with palpation and no discharge noted.  Tympanic membranes intact with no perforation noted.  No cerumen noted bilaterally.

 

Nose:  Nares patent with no septal deviation noted.  Mucosa pink, no lesions or discharge noted at present.  No sinus tenderness.

 

Mouth:  Mucosa and gingivae pink, no lesions masses or bleeding.  Teeth are in good repair with upper bridge noted.  Tongue is symmetric, midline.  Pharynx is pink, there is no exudate.  Uvula midline, tonsils are normal size.

 

Neck:  There are no masses or tenderness and no lymph node enlargement.  Thyroid is not enlarged or tender.  Trachea midline.  Full ROM noted.

 

Spine and Back:  No scoliosis, lordosis or kyphosis noted.  No tenderness or limited ROM.  No CVA tenderness.

 

Thorax and Lungs:  AP< transverse with symmetrical chest expansion. Respirations unlabored.  Tactile fremitus equal bilaterally.  Lung fields clear bilaterally with no adventitious sounds noted. 

 

Heart:  Skin pink, no cyanosis noted.  Capillary refill brisk, no clubbing.  No peripheral edema.  No thrill.  Apical rate 72 with a regular rhythm.  S1-S2 are not diminished or accentuated.  No murmur noted.

 

Abdomen:  Round. Bowel sounds present in all quadrants, no bruits noted.  No organomegaly present.  Abdomen pain, soft, no masses or tenderness.

 

Extremities:  right middle finger tip and nail amputation.  No edema noted.  All peripheral pulses are present, 2+ bilaterally.

 

Musculoskeletal:  There is no crepitation or pain in the TMJ.  Full range of motion of extremities, neck and back.  No pain or crepitation noted.  Muscle strength is equal bilaterally.

 

Neurologic:  The patient is alert, and oriented X 4. Speech is clear, comprehension.. Remote and recent memory retentive.

 

CN V: Facial sensation is intact to pinprick in all 3 divisions bilaterally. Corneal responses are intact.

 

CN VII: Face is symmetric with normal eye closure and smile.

 

CN VII: Hearing is normal to rubbing fingers

 

CN IX, X: Palate elevates symmetrically. Phonation is normal.

 

CN XI: Head turning and shoulder shrug are intact

 

CN XII: Tongue is midline with normal movements and no atrophy.

 

Motor:

 

There is no pronator drift of out-stretched arms. Muscle bulk and tone are normal. Strength is full bilaterally. 

Reflexes are 2+ and symmetric at the biceps, triceps, knees, and ankles. Plantar responses are flexor. 

Rapid alternating movements and fine finger movements are intact. There is no dysmetria on finger-to-nose and heel-knee-shin. There are no abnormal or extraneous movements. Romberg is negative.  Posture is normal. Gait is steady with normal steps, base, arm swing, and turning. Heel and toe walking are normal. Tandem gait is normal when the patient closes one of her eyes.

 

ASSESSMENT

 

Migraine Headache

Deficient Knowledge about balanced diet R/T cholesterol levels

Self-care deficit: R/T sun exposure

 

Health Promotion Plan:

2. Educational Video on Low Cholesterol Diet (monitor cholesterol Q 6 months)
3. Education on use of sunscreen. Educate patient of daily use of sunscreen since he works outdoors.
4. Education handout regarding foods that can trigger migraines.
5. Education on yearly flu shots.
6. Monitor Asthma symptoms and management.