History and Physical Exam
Comprehensive
Back pain, Sexual dysfunction, elevated blood pressure, diabetes
AW is a 69-year-old gentleman who has come into the office as a new client to the clinic. His wife is a patient here and he would like to be seen as well. He is a white, married male who converses easily and knowledgeably. Source of this history is from the client and from the medical record when indicated (*).
Chief Complaint
AW presents with three areas of concern today.
1) Back pain. AW has noticed considerable lower back pain lately. The pain has occurred and intensified over the past two months. He can localize it to each side of the lumbar spine area. The pain does not radiate into his legs. There is no associated numbness or tingling in his legs or feet. He believes that it began when he was doing yard work in March during a warm spell. It feels worse late in the day. He gets some relief when he lies down but he does feel stiff after lying too long. He has used Tylenol gr X and a heating pad at night. He has some relief but he is concerned because it is not completely gone. He sits for long periods at his computer. He thinks it may be a “pull.”
2) Sexual dysfunction. AW states that he has not been able to maintain an erection for 3 years. He first noticed problems before he was diagnosed with diabetes and was told by his previous physician that it is due to his diabetes. He states that he is living with it but is wondering if there is some new treatment available. He discussed this with his previous physician at the other clinic. He had a complete workup including hormonal lab work and a prescription for testosterone (*). AWstates the hormone didn’t improve his function so he stopped taking it after 6 months.
3) Elevated blood pressure. Upon arrival to the clinic, AW’s blood pressure was 190/98. After twenty minutes, his blood pressure was 180/90. Previous blood pressures obtained were 160-170/80s (*). AW denies feeling nervous at this visit but does admit to feeling a lot financial stress due to the tax season.
Past History
General state of health. Client has been feeling well lately. He has been able to maintain his usual activities of daily living despite his sore back.
Childhood Illnesses. Measles and mumps as a child. No known sequela.
Adult Illnesses. Client has been a non-insulin dependent diabetic for 4 years. He has been on insulin for the past 14 months.
Psychiatric Illnesses. None.
Accidents and Injuries. None.
Operations. None.
Hospitalizations. None.
Current Health Status
Allergies. NKMA. Denies sensitivities to environmental allergens.
Immunizations. Client is unaware of his last Td booster. He states that he has had a flu shot in November (*). Pneumococcal vaccine 2 years ago (*).
Screening tests. Annual visits to the dentist, and ophthalmologist. Proctologic flex-sig exam 3 years ago.
Environmental hazards. Client lives in a 1-story home with his wife in the metro area. Denies environmental concerns.
Safety measures. Client wears a seatbelt at all times. Locks doors of his home at night. Denies any problems with falls.
Exercise and leisure activities. Client denies a regular exercise regimen. He enjoys working in the yard in the warm weather. He also collects and enjoys model airplanes.
Sleep pattern. Usually can sleep 6-8 hours at night but his back pain has been preventing him from getting in a comfortable position to fall off to sleep easily.
Diet. Client states he follows an ADA diet and avoids all sweets.
Current medications.
Insulin 20u NPH & 36u Regular Humulin q am.
Insulin 16u NPH & 12u Regular Humulin q pm.
Tylenol gr X q 4-6 hr prn.
Tobacco use. Never.
Alcohol/illicit drug use. Never.
Family History
AW is married to his wife of 43 years. Both his wife and 4 children are healthy. His father died at 84 of CHF. He had an MI at 48 yrs and was an insulin-dependent diabetic. His mother died at 79 yrs of Alzheimer’s. His 70 yr old sister has rheumatoid arthritis.
Psychosocial History
AW states he is close with his children and enjoys spending time with them and his 8 grandchildren. He is a computer consultant who operates out of his home. He was laid off from a large corporation in the metro area 3 years ago and now operates independently. He admits to not feeling as financially secure as he would be if he were still with the company. His wife has a good job as an elementary school teacher and carries the health insurance for both of them. He is a member of the Lutheran Church and attends irregularly. His social circle has diminished since he was laid off, which is “O.K.” Although his financial future is uncertain, he is optimistic about his life.
Review of Systems
General: Feels pretty good except for the back pain.
Skin: No complaints of bruising or non-healing sores; uses sunscreen.
Head: No complaints of headaches or tenderness.
Eyes: Wears glasses, denies difficulty with vision.
Ears: Denies drainage, tenderness, or difficulty hearing.
Nose, sinuses, and throat: Denies difficulty with smell, taste, sinus tenderness, or drainage.
Mouth: Denies difficulty with chewing or swallowing.
Neck and lymphatic: Denies stiff neck or swollen glands.
Respiratory: Denies hemoptysis, bronchitis, pneumonia, or TB.
Cardiac: Denies angina or associated symptoms.
Gastrointestinal: Denies nausea/vomiting, heartburn, food intolerances, bloating or cramping. Daily bowel movements of normal consistency.
Urinary: Denies difficulty with starting flow, burning, or pain. Does get up 1 time at night to empty his bladder.
Genital: Denies lesions or discharge, unable to maintain an erection for intercourse.
Peripheral/Vascular: Denies numbness, swelling, or decreased sensation.
Musculoskeletal: Low back discomfort on bilateral sides of lumbar spine.
Neurologic: Denies fainting, dizziness or involuntary movements.
Hematologic: Denies bruising easily, never had a transfusion.
Endocrine: Denies heat or cold intolerances.
Psychiatric: Denies feeling depressed or suicidal.
Physical Exam
General Survey. AW is an alert, oriented, articulate male. BP 190/98 and 180/90, pulse 88. RR 20. T 98.4. Ht. 5’11”, Wt. 190.
Skin. Intact throughout. Skin warm, dry, some flaking on lower legs. Nails short, clipped.
Head. Hair is graying, full, shiny, evenly distributed; scalp and skull without tenderness or masses.
Eyes. PEERLA, EOMs intact without nystagmus; sclera white without discharge, eyes and brows symmetrical.
Ears. Pale, smooth, pain-free to touch, canals and drums clear; acuity intact to whispered voice test.
Nose/sinuses. Mucosa pink without drainage; sinuses non-tender.
Mouth. Mucosa pink, intact; teeth intact; gums and pharynx pink and non-tender, tongue and uvula midline.
Neck/lymph nodes. Trachea midline, no nodules; no detectable nodes.
Thorax/lungs. Thorax symmetrical; lungs clear without adventitious sounds; no CVA or spinal tenderness; no masses in breasts.
Cardiac. Regular apical pulse at the ICS; no lifts, heaves, thrills, gallops or murmurs; no JVD, no carotid bruit.
Peripheral/vascular. 3+ radial and pedal pulses; no edema, cyanosis, clubbing; negative Homan’s sign; sensation intact to lower extremities.
Abdomen. Soft, round, non-tender to palpation; no masses; bowel sounds active x 4 quads; liver and spleen non-palpable.
Musculoskeletal. No joint deformities; full range of motion of arms and legs; muscular tenderness along bilateral lumbar spine with discomfort at 30 degrees extension and 50 degrees flexion; negative radiating pain.
Genitourinary. Testicles descended bilaterally; no penile drainage; no masses or lumps palpable in scrotum; no inguinal hernias.
Rectum. Rectum without masses; prostate smooth with nodules; no hemorrhoids.
Neurologic/psychiatric. Alert, oriented x 4, cooperative and pleasant; speech clear, 2+ reflexes throughout; CN II-XII intact; sensory function intact; gait and balance intact.