Complete History and Exam
Problems with balance, fall risk, chronic pain, poor memory
GM is a 68 y/0 Caucasian woman with balance problems. She is a poor historian.
Chief concern:
1. MVA with minor head injury and rear-end whiplash. Current difficulty with reading, following written instructions, reading comprehension decreased, concentration poor, phone communication difficult, hears numbers wrong. She has tried to leave notes for herself to do things but loses them. Has SSDI for disability.
2. Chronic pain since accident – see ROS
PAST HISTORY: Prior to MVA, good health. MVA 1992. Tonsillectomy approximately age 13 years.
CHILDHOOD ILLNESSES: Mumps, measles, chicken pox.
ADULT ILLNESSES: Toxemia with first child.
HOSPITALIZATIONS: Esophagitis, childbirth vaginal delivery
PSYCH ILLNESSES: Previous episodes of counseling since MVA, hasn’t continued sessions, feels she doesn’t need it and is becoming “labeled.”
OPERATIONS: Hemorrhoidectomy. Carpal tunnel repair
ACCIDENTS/FALLS: MVA, Multiple falls since in home. Unable to give specifics on frequency without injuries from falls.
CURRENT HEALTH:
ALLERGIES: Sulfa- severe body aches, rash swelling. Food sensitivities are numerous. Oranges; sores in her mouth, upset stomach, yeast, nausea, bloating, constipation. Lactose intolerant; nausea, stomach pain. Molds, glutens, fermented products, cause nausea, stomach pains. Perfumes cause sinus stuffiness, nausea, headaches; all of these sensitivities have been for approximately 15-20 years.
SCREENING TESTS/HEALTH MAINTENANCE: Last tetanus; she is unsure of. She has not had a flu shot. Dentist two times a year cleaning. Ophthalmologist one time a year. Chiropractor for five years for neck and back, seeing this person 2-3 times a month now. Last PAP & pelvic 1-½ years ago. Mammogram two years ago. Colon cancer screening times one, negative.
Wears seat belts. Smoke detectors in the home. Fire extinguishers.
EXERCISE/LEISURE: Doesn’t do much for leisure; US Swim and rehab for exercise several times a week.
Sleep 6-7 hours currently, some nights five hours. Not a deep sleep. Needs eight hours per night. Did not have problems with sleep prior to the accident, now she wakes up during the night an can’t fall back to sleep, taking something called 40 Winks for Sleep and Com’s Forte.
DIET: She doesn’t eat much meat, uses herbs and spices, minimum sugar, soy milk, few canned or processed products, some ice cream or yogurt, lots of fruits and vegetables, bakes her own bread. Cannot tolerate acidic foods, nausea, sores in her mouth.
MEDICATIONS & HERBAL REMEDIES: Currently taking Ibuprofen as needed 200-400 mg 1-2 times a week. Nortriptyline 1- mg 3 times a month, 40 Winks (it’s Valerian) 1 tablet 4-5 times a week. Com’s Forte (passion flower) not taken for the past six months, but has taken it prior to that. Calcium 1500 mg, Alimental qd, multivitamin qd for two years, kelp 1 tablet qd, Murine eye cream every h.s. Isotears q 2-3 times a day. HCL as needed for digestion 10 times a month, Antivert p.r.n. for dizziness, falls about one time a month.
HABITS: Smoked 23 years ago not specific on length or amount. Denies alcohol or illicit drugs. Four cups of coffee daily.
FAMILY HISTORY: Mother age 66 living, heart bypass, HTN, heart disease. Father age 68 died of stroke, emphysema, diabetes, questionable cancer. MGM 80 years, died questionable stroke, diabetes. MGFR, not known, died when mother was young. PGM 80+ years, died in nursing home, not known history. PGF 80 years, died not knowing history. Children – 2 sons, both healthy.
PSYCHOSOCIAL: Lives home with husband and two sons, second marriage without children. Two sons going to college. Working prior to the accident as a secretary. Wants to start doing volunteer job in the future, MVA changed her life, used to be very alert and organized.
ROS:
GENERAL: Feels weak, chronic pain, not as together as she used to be. Client states memory is bad and not a good historian.
SKIN: Denies problem.
HEAD & NECK: TMJ not specific length of time or frequency. Headaches, pressure pain, back of the head, comes and goes; 2 out of 7 days, some days 6-7 times, some days 1-2 times. Ibuprofen helps some. Sinus headaches 2-7 times a week, year round, no general pattern for 9-10 years. Sees chiropractor to adjust neck and ultrasound 2-3 times a month. Uses magnetic mattress on bed with some relief for the last three months. Denies dryness of scalp.
EYES: New prescription recently last month. Denies glaucoma or cataracts. 15 years ago diagnosed with congenital cyst on cornea, difficulty with night vision, difficult to focus in dark, daily irritation from dust, gritty feelings in eyes. Sensitive to light. Difficulty seeing with changes in light, uses Muriel 28 cream, uses Iso-Tears during the day to keep lubricated.
EARS: Denies itching or discharge, denies ringing in ears, problem hearing.
NOSE: Denies any current problems with secretions or stuffiness.
MOUTH/THROAT: Denies any problems, sore throat, cough, mucous.
NECK: Decreased ROM. Neck pain, feels some muscular problems related to MVA. Denies swollen glands.
BREAST: Left breast fibrosis tenderness in past, all mammograms negative, denies any lumps palpated with breast exams, does occasional breast self exam.
RESPIRATORY: Denies SOB or orthopnea, wheezing.
CARDIAC: Denies palpitations, chest pain, angina.
GI: Stools formed, constipation 1-2 times a month. Herbal laxatives help. Trying to drink more water, gas and indigestion for 15-20 years when eating dairy, beans, rice. HCL helps, stopped eating dairy 24 years ago, improved. Avoids beans and rice when possible.
GU: Since menopause, “emotionally tired”, denies any urinary problems, sleep problems, breast tenderness or hot flashes. Since MVA, though night sweats four times a week. Last month and a half has decreased to 1-2 times a week, not sure why. Tried hormones. Progesterone made her agitated times six months. Took Estrace for three months - doesn’t remember the dose or exact length of time.
OB/GYN: 2 vaginal deliveries, difficult long labors, one premature baby.
PERIPHERAL VASCULAR: Denies coldness in feet, edema, swelling.
ENDOCRINE: Denies problems with thyroid, changes in appetite, intolerance to cold. Less energy for activity - needs to stop and rest 2-3 times a day for 30-60 minutes.
HEMO: Denies blood transfusions, bruises, or easy bruising.
MUSCULOSKELETAL: Pain neck, constant always on guard, stiff, sharp feels ROM limited, numbness hands and arms turning neck. Pain can go down back into upper back and trapezius. Has had 15 years seeing chiropractor. Exercises and stretches 1-3 times a day, one hour in the morning, swims in the pools 45-90 minutes 3-4 times a week.
Knees sharp, stabbing pain with movement or subtle aches. Stopped biking. Walking on uneven surfaces, standing causes pain in the knees now, Ibuprofen helps minimally.
LEGS: Right leg constant tightness, aching, left leg, pulsing, stabbing pain.
Low back and buttocks; old pain 15 years stiff, couldn’t sit. Chiropractor helped, leaning back irritates pain, shoots down to hips and buttocks, worse on right, stabbing, pulsing, throbbing, cutting, tender to touch. Takes Ibuprofen two 200 mg tabs 1-w times a day with some relief. Exercise helps mobility and increases flexibility. Constant pain still present in any position. Never had regular therapeutic massage. Multiple MRIs and bone scan found "bony island” on right hip. Muscles in general feel weaker since accident. Had chronic pain assessment but vague on conclusions.
NEUROLOGICAL: Arms feel “on fire” spread all over and into legs sometimes both sides since MVA. Not found anything to help. If active and busy, walking makes it worse. Approximately 6-20 times a week can happen when doing nothing. No pattern. Sometimes stabbing makes her cry out in pain. Predominantly right side, may happen six times a day then not again for a week. Notices it more with sitting. Neurologist gave her Nortriptyline but she doesn’t like the side effects, feels it makes her more confused. Episodes of dizziness and falling. Legs give out, no warning, 2-3 times a week, has seen neurologist, has tried Antivert, doesn’t like side effects, no black-outs, no injuries.
PHYSICAL EXAM: Skin dryness in arms, warm and moist to the touch, pink color.
Head: Without tenderness, lesions, masses.
Ears: Hearing intact to whisper test. Canals clear, eardrums visible.
Eyes: Nystagmus, all six fields, lateral worse. Pupils round, sluggish to light. Able to read normal print with glasses at 24 inches, unable to do more extensive exam.
Neck: Tenderness on palpation with minimal pressure of trapezius or rectors, levator, scapula, lymph nodes, non-palpable. Thyroid not palpable. Trachea mid-line.
Mouth: Buchal mucosa and gums pink. Multiple fillings without dentures. Tongue midline.
Respiratory: Lungs clear, perfusion to base is equal expansion without kephosis.
Heart: Pulse regular, rate, rhythm normal without thrills, heaves, without SOB, with movement.
Abdomen: BS within normal limits, all four quadrants, no masses or tenderness noted on palpation.
GU: Deferred, will do PAP pelvic, subsequent visit.
GI: Deferred.
Breast: Symmetrical, some tenderness on palpation bilaterally upper quadrants. Lymph nodes non-palpable nontender.
CV: Without edema, lower extremities, capillary refill WNL. Pulse is present, strong bilaterally. Feet warm to touch.
MS: Tenderness neck, shoulders, hips, knees, ankles on palpation.
Neurological: Difficulty with gag reflex, saying “ah,” other cranial nerves intact. Strength 5/5 bilaterally. Arms, legs grip. Cerebella intact. Rhomberg normal. Extensive neuro exam to follow. Reflexes +1.