H&P

 

BIOGRAPHIC DATA

 

Name: Joshua R. Smith, prefers to be called Josh

Address: 106 NE 28^th Ave. Ocala, FL.

Marital Status: Married

Source: Patient – Seems to have a good understanding and recollection of current health.

Reason for seeking care: The patient is a 28-year-old male suffering from reoccurring headaches and reports today with complaints of headache and sinus pressure.

 

History of present illness: Mr. Smith states that the present condition originated 3 years ago mid –March when he experienced off and on headaches of a 10/10 pain score for about two weeks and then condition subsided. Sought medical attention at local walk in clinic but only high dose Tylenol offered. Condition repeated itself last April with the same type of headaches and patient reports he just “dealt with them.” Headaches represented approximately, one week ago and at least one, sometimes two have occurred daily. Reports no known trigger to onset headaches, but when headaches present feels as if he cannot move the pain/pressure is so intense. Also this time watering eyes, a runny nose and a feeling of head “congestion accompany the headaches

    

     Mr. Smith denies any visual changes during these episodes but reports that when they come on he

     typically goes to a darkened room, lays down and closes his eyes, to alleviate intense pressure, until

     the headache passes which sometimes takes “hours.” Patient reports that he actively works out,

     usually 4-5 times weekly and that during this present onset, he has had to stop his workout session on

     three separate occasions due to a headache developing. Denies recent or past head trauma, recent  

     illness, fever, tinnitus or other neurological symptoms.

 

PAST HEALTH

 

Childhood Illnesses: Received all childhood immunizations and currently up to date with no measles, mumps, croup, pertussis, polio or rheumatic fever noted. Repetitive asthma attacks as a child, but resolved during adolescence. Has not used an inhaler since high school.

 

Accidents: ACL torn at age 16 during football game and torn a second time at age 17 during football practice. MVA in 2013 when deer ran into vehicle on drivers side, reports no injuries sustained, air bags did not deploy.

 

Chronic illnesses: Migraine headaches began in March of 2014 and represented April 2015, and currently March 2016.

 

Hospitalizations: Age 3 months cataract surgery on left eye, repeated again at 5 years. ACL repair in 2002 and 2003.

 

 

Last Examinations: Eye exam 2012. Well Exam and routine labs September 2015. Repeated exam October 2015 due to radiating back pain after a Crossfit competition- CT of spine suggested disc inflammation and slight deterioration, 6 weeks of physical therapy completed and patient reports pain has subsided and he resumed exercising around the first of the year. During this time took up running and suffered a navicular foot fracture, boot prescribed but not worn, insoles prescribed, worn for 8 weeks, repeat MRI on foot shows fractured healed.

 

Allergies: No known drug or food allergies.

 

Current Medications: Naproxen 500mg po Q12H PRN, Flexeril 10mg po PRN muscle spasms ( reports has not taken since January of this year), Advil 1-2 tabs po PRN headaches, Tylenol 500 mg po PRN headaches , Ibuprofen 600 mg po PRN headaches. Nasacort 1 spray each nostril Q24H PRN.

Daily multivitamin po in am – GNC brand. Tums 2 tabs po PRN.

 

FAMILY HISTORY:

 

Family History Abnormalities :

Paternal Grandfather: Rheumatoid Arthritis and Osteoporosis

First Cousin Paternal side: Epilepsy and Fibromyalgia

Maternal Grandfather: Heart stints x2 and hx of Skin Cancer ( nose)

Maternal Grandmother : Incognita Pigmenti

Maternal Aunt : Hx of Bladder Cancer

Maternal Aunt ( Mother’s fraternal twin) : Incognita Pigmenti

Maternal Uncle: MVA resulting in death prior to patient’s birth – unsure of any other health concerns

Mother: Incognita Pigmenti, currently in remission for Pancreatic Cancer

Father: Diverticulosis

Sister: Incognita Pigmenti and currently 13 weeks gravid, no known concerns with fetus.

Patient: Chronic seasonal cluster Headaches, Legally Blind in left eye, and hx of childhood Asthma

 

 

REVIEW OF SYSTEMS- HISTORY

General Health: Patient states that he is in good health, minus the headaches, with no fatigue, weakness, fever or night sweats. Patient has been following a “healthier” lifestyle since the beginning of the year and alternates between paleo and clean eating plans which has resulted in a 15lb weight loss over the last three and a half months.

 

Skin: Tan skin, patient reports he works outside but does wear sunscreen due to his grandfather’s hx of skin cancer. No personal history of skin cancer, rash, or lesions other than chicken poxs when he was a child. No reported changes in hair texture or hair loss reported/observed.

 

Head: Severe headaches on and off during the months of March and April in 2014, 2015, and currently. Reports no previous concussion. Denies syncope, dizziness or vertigo.

 

Eyes: Does not wear corrective lenses, although legally blind in left eye from birth due to cataract, reports 20/20 vision in right eye.

Denies pain or pressure in eyes at this time, but intense pressure behind eyes during headaches. Last eye exam 2012. Reports his left sided blindness does not bother him as this is all he has ever known. States he can see fuzzy images out of eye but cannot make out faces, numbers or shapes. Reports normal vision with right eye. Watering of both eyes for the past week since the headaches have come on.

 

Ears: No reported hearing loss or difficulty. No report of ear infections, pain, or drainage. No recollection of having a hearing screen performed. Reports he cleans his ears on a weekly basis with q-tips and every few months his wife “candles” his ears.

 

Nose: Occasional clear nasal discharge during the past week. No sinus pain. Denies any change in sense of smell.

 

Mouth and Throat: Patient denies lesions in mouth. Denies toothache- last annual dental exam in fall of 2015 showed no caries. Brushes teeth in am and pm, ocassially flosses. Denies cigarette or chewing tobacco use.

 

Neck: Denies neck stiffness or pain. Reports no changes in ROM.

 

Breast: Denies pain, lumps, rash or discharge. No history of male or female breast cancer in the family. Does not do self -breast exams.

 

Respiratory: No history of lung disease, other than childhood asthma that resolved in adolescence; last inhaler used in high school. No chest pain, SOB, wheezing or cough noted. No history of smoking and denies ever living with a smoker. Profession is pest control and states he generally uses PPE equipment when spraying, but sometimes when it is too warm he does not wear a mask. Last TB test 2015, negative result.

 

Cardiovascular: No reported chest pain, palpitations, or hx of arrhythmia. Cholesterol levels at last well exam within normal limits. No dyspnea on exertion or at rest. No cyanosis or circulatory issues. No history of blood clots.

 

Peripheral Vascular: No reported numbness or tingling in extremities. Is primarily on feet entire workday. Does not wear support hose. Has never noticed coldness or change of color in upper or lower extremities.

 

Gastrointestinal: Reports no change in appetite and eats 5-6 meals a day since beginning his clean eating diet. Occasional upset stomach when spicy foods ingested, usually treats with OTC Tums. Denies current N/V or onset with headaches. Reports no stomach pain, history of IBS. States appendix and gallbladder are intact and has never had any issues. Normally defecates 2-3 times a day. Firm, but soft, formed stool of light brown color.

24-Hour Intake:

1-Gallon Water

1 cup of coffee with breakfast – black

3 eggs with minimal salt and pepper

2 veggie sausage patties

3 6oz chicken breasts with ½ cup (total 1 ½ cups) of mixed veggies spaced out every 2-½ hours (1200, 1430, 1630)

8 oz grilled salmon with 8 stalks of asparagus and ½ cup of brown rice

Protein shake

1 large glass of milk

 

 

Urinary: Reports no nocturia, dysuria, hesitancy, straining, urgency or frequency. Reports urine is pale yellow in color with no noted foul odor, sometimes brighter in am after morning daily vitamin.

 

Genitalia: No penile or testicular pain. No lesions or bumps. Denies penile discharge.  

Sexual Health: Reports he is sexually active and in a monogamous relationship. Condoms used occasionally. No changes in erection or ejaculation. Patient and partner satisfied with sexual relationship. No awareness of partner having contact with anyone having syphilis, herpes, chlamydia, or other STDS. Patient has no history of STDS. Partner uses oral contraceptives daily.

 

Musculoskeletal: No c/o of joint pain or tenderness. History of back pain following exercise injury but has undergone therapy and it has subsided. Denies cramps, muscle pain, or weakness. Is flatfooted.

Self Care: Routinely exercises 4-5 times a week intense cardio/ weight lifting for 1-hour sessions. Follows up with stretching program lasting 20 minutes.

Neurologic: Denies any present or past thought of suicidal ideation. Feels physically and emotional safe at home where he lives with his wife. No history of seizures or fainting, or memory problems. Denies anxiety or depression past or current.

 

Hematological: Has never had a blood transfusion. Does not bruise excessively. No swollen lymph nodes.

 

Endocrine: No history of diabetes or hyper/hypothyroidism in patient or patient’s family. Denies intolerance to heat and cold. No changes in nails, skin, or hair. Denies excessive thirst , excessive voiding. Sweats moderately, but works outside in hot climate.

 

FUNCTIONAL ASSESSMENT

 

Self-Concept: Graduated from high school and has an AA degree from a local community college. Has held several jobs since graduation. Currently employed as a lawn care technician for the past four years. Not an ideal job, but not dissatisfied with job either. Would like to go back to school and pursue a Sports Medicine degree. Raised in a Christian home and attends services three times a week. Feels satisfied with life but wishes to move on to a career instead of a job.

 

Activity-Exercise: Typical day: Wakes at 6:00AM, prepares for work and makes breakfast. Drives 45 minutes to job. Patient reports his job can be stressful at times, especially during this time a year when spraying and termite treatments are picking up. No set lunch time, but patient brings his own prepped meals and swings into convenient stores and uses microwave to heat up meals. Once home, around 6 pm, Mr.Smith reports he changes and heads to crossfit. He reports he usually gets home around 8:15 pm and takes a shower and then eats supper his wife prepared him while they lounge on the couch and watch a Netflix episode. After this he preps his meals for the next day and sets out his clothes for the following work day before going to the bedroom where he may browse YouTube for an hour or so.

 

Sleep-Rest: Bedtime around 11 PM, turns on classical music on Ipod when ready to go to bed. Does not use sleep aids and hardly ever wakes up during the night. Averages 7 hours of sleep each evening. Only takes naps on Sunday afternoons in between church. Feels tired upon waking but quickly gets a “second wind” of energy.

 

Nutrition: 24-hour menu recall was as follows:

1 Gallon Water – dispersed over entire day

1 cup of coffee with breakfast – black

3 eggs with minimal salt and pepper

2 veggie sausage patties

3 6oz chicken breasts with ½ cup (total 1 ½ cups) of mixed veggies spaced out every 2-½ hours (1200, 1430, 1630)

8 oz grilled salmon with 8 stalks of asparagus and ½ cup of brown rice

Protein shake

1 large glass of milk

No known food intolerances.

 

Alcohol/Drug: Denies recreational drug use in past or present. Does not consume alcohol products on a regular basis but did have a glass of wine on Valentines Day of this year.

 

 

Interpersonal Relationships: Reports a fulfilling childhood. Aunts and Uncles lived close by and has several cousins around the same age and have remained close. Currently married for three years to his college sweetheart. Reports a happy marriage and plans to start a family next year. Wife is strong support system and “balances” me. States he is actively involved in church and has several church friends. Best friend currently has had a son and has not been able to hang out as much but patient states this is understandable. Very close to parents and goes home to visit about twice a month and stays for the weekend. Wife comes with him on these visits, unless she is working.

 

 

Coping and Stress management: Reports a strong religious support system and usually prays and looks to God, wife and church family during times of crisis (Mother recently underwent treatment for pancreatic cancer and is now in remission). Also stretches and listens to classical music on a daily basis. Currently feels financially stable and no present stressors noted.

 

PERCEPTION OF HEALTH

 

States he feels like he lives a healthy lifestyle but is concerned about these headaches as they are intense and incapacitating when they set in. Does not get sick days at work, and although wife works as well, cannot afford to take off several days from work until the headaches pass. Headaches do not seem to have triggers and pop up at various times throughout the day.

MEASUREMENT

 

HGT: 77 inches
WT: 245 lbs.

B/P: 136/82

Temp: 98.8

Pulse: 62 regular

Respirations: 16 unlabored

 

General Survey: Josh is a 28 year old male. No difficulty with ADLs, follows an active exercise regimen, and has no difficulty with articulation or gait. However, currently experiencing severe headaches, which are causing him to seek medical attention.

 

HEAD TO TOE EXAMINATION

 

Skin: The skin is dry and intact. Good skin tugor upon assessment. Patient of Caucasian descent and has tanned arms and face due to working outside, rest of torso normal for race. States he does use sunscreen. Birthmark on left arm, light colored about 5 cm, oblong shape. Nail beds are pink and firm with brisk capillary refill less than three seconds bilaterally. Hair is normally distributed, good texture, no lesions noted on scalp or anywhere else on body. One mole on upper right posterior shoulder area. Raised, light brown color, symmetrical but jagged borders, 2 cm. Patient states it has been there as long as he can remember.

 

Head: Normocephalic. No involuntarily movements observed. Face is symmetrical with slight deviation of nose. No scars or active lesions noted on face. Skin intact, tan pigmentation.

Eyes: Conjunctivae is pink in color, sclera white with no broken blood vessels. No lesions or discharge seen bilaterally although patient reports eyes have been watering over the past week. Right eye 20/20 vision with use of Snellen chart. Left eye vision range not assessed due to patient reporting being legally blind and only able to make out fuzzy images with left eye. Left eye does react to light although slowly, and is 4mm. Left eye slightly deviated, patient reports he wore a patch as a child to try to correct this. Right eye 4mm and reacts briskly to light. Able to assess all visual fields with normal visual acuity in right eye.

 

 

 

Ears: No tenderness upon palpation of outer ear. No masses, keloids, piercings, or lesions noted. No discharge from ears observed. Left ear tympanic membrane shiny grey, no perforation, no redness or swelling of ear canal and minimal cerumen. Right ear canal upon assessment appears 90% impacted and tympanic membrane cannot bee visualized. Patient denies hearing loss or changes.

 

Nose: Nares patent. Slight septial deviation towards right, patient states that it has always been this way and cannot recall any nose trauma or falls during childhood. Pink mucosa upon examining nares, with no visible lesions. Currently no drainage noted but patient reports nose has been draining on and off over the last week. Patient reports he did try OTC “Nettie Pot” for relief. Slight palpable sinus tenderness overall frontal sinuses bilaterally.

 

Mouth: Palate intact. Pink mucosa noted with no bumps, spots, or lesions. Upper teeth crowded, overbite noted. States he wore braces for four years during middle school, but teeth re-shifted. Does not wear retainer. No present caries observed, two previous fillings observed on back left bottom molar. Uvula midline. Phyranx pink, no lesions noted.

 

Neck: There are no visible or palpable masses or tenderness along neck and jaw. No lymph nodes palpable. Trachea midline, with no tenderness or enlargement of thyroid noted. Full ROM demonstrated by patient without difficulty.

 

Spine and Back: Spine midline. No kyphosis, lordosis, or scoliosis upon assessment. No tenderness or limited ROM. States he had been experiencing severe pain in lower back but recently completed 6 weeks of physical therapy and has not experienced discomfort for about 3 weeks.

 

Thorax and Lungs: Respirations even and unlabored while sitting. Tactile fremitus bilaterally equal. Lung fields clear bilaterally anteriorally and posteriorally with no adventitious sounds auscultated. No cough noted. O2 sat 100% room air. Chest expansion symmetrical with AP < transverse ratio.

 

Heart: Skin color normal for race with no paleness or cyanosis noted. No generalized or peripheral edema observed. Patient denies numbness and tingling of extremities. Upper and lower extremities warm to touch, and skin is dry and intact. Capillary refill less than three seconds nails beds appear normal. Apical pulse auscultated and revealed rate of 62 bpm with a regular rhythm. S1-S2 is normal. No murmur auscultated. Apical impulse palpable at 5^th intercostal space mid-clavicular line.

 

Abdomen: Abdomen soft, no visible masses or lesions. No palpable masses or organmegaly. Bowel sounds active in all quadrants. Last BM this morning, reports regular pattern 2-3 times daily. Able to pass flatus. No hemorrhoids. Flat slightly rounded contour with abdominal muscle definition.

 

Extremities: Left leg has two scars, one 7 cm , one 4 cm, in length running vertically down anterior portion of knee. Patient reports these are from his ACL surgeries. Also round 2 cm scar on medial right side of same knee, patient reports that a large needle was placed here to drain the fluid that had accumulated after his second injury. Scars are lighter than patient’s skin tone. Peripheral pulses palpable in all locations and are 2+.

 

Musculoskeletal: No stiffness or tenderness noted. Normal gait. Pes planus noted bilaterally, patient reports he wears insoles for arch support. Able to demonstrate full ROM of neck, extremities, and back. No crepitation or pain noted. Muscle strength equal in upper and lower extremities. No tempormandibular joint pain. Able to perform ADL’s without assistance, No assistive devices used for ambulation.

 

Neurologic: Mr.Smith is alert and oriented to person, place and date. Able to articulate words clearly, no facial drooping noted. Short term and long term memory appear to be intact. Denies history of seizures or depression. No anxious behaviors observed.

 

CN I: Able to differentiate smells with eyes closed. Correctly identified coffee, peppermint and vinegar.

CN II: 20/20 Vision Right eye via snellen assessment. Red reflex intact.

CN III: Pupils constrict bilaterally, although more sluggish on left eye. Able to open and close both eyelids.

CN IV: Able to move eyes down and inward.

 

CN V: Able to differentiate between light and dull sensations on face in all locations. Able to identify liquids as hot or cold with tongue.

 

CN VI: Able to move eyes laterally.

 

CN VII: Able to close eyes, smile, close and open mouth, puff out cheeks.

 

CN VIII: Able to hear whispered words and rubbing of fingers.

 

CN IX, X: Gag reflex intact. Demonstrates swallowing. Correctly identifies taste: chocolate and salt. Normal phonation.

 

CN XI: Able to shrug shoulders and turn head side to side.

 

CN XII: Tongue is midline. No atrophy noted. Able to move side to side.

 

Motor: Negative Romberg test. Heel to toe walking performed WNL. Normal posture noted. Strong hand grasps bilaterally. 2+ symmetrical reflexes of knees bilaterally. Plantar responses are flexor. Strength bilaterally the same, no weakness or stiffness noted. No atrophied muscles, muscle tone normal. Steady gait to and from chair. No twitches or abnormal movements observed. Able to bring finger to nose.

     There is no pronator drift of out-stretched arms.

 

ASSESSMENT – Potential Health Risk :

     Seasonal cluster headaches

Right impacted ear

Upper sinus infection

 

Acute pain R/T seasonal cluster headaches AEB Patient reporting headaches a 10/10 during springtime

Acute pain R/T Increased Intracranial Pressure AEB headaches becoming severe during exercise sessions

Self-care deficit: R/T insecticide exposure

Self care deficit: R/T impacted right ear

 

Health Promotion Plan:

1. Referral for MRI of brain to rule out any malignant source of headaches
2. Education on polypharmacy and proper analgesic intervention when headaches occur.

 

3. Allergy Test (Rule out allergies to hay, pollen, rag weed etc.)
4. Education on use of PPE when using insecticides/ working with chemicals
5. Irrigation of right ear.

6. Refer for biopsy of mole and teach patient ABCD method to evaluate skin