Ihuman MABEL JOHNSON Week 9 Recently Updated 2023

Ihuman MABEL JOHNSON Week 9 Recently Updated 2023






Episodic Focus Note


Patient Information:MJ, 76 y/o, Female.
Subjective:
CC Knee pain

HPI: Mrs. Mabel Johnson is a 76 y/o female who presented with bilateral knee pain that has been increasing over the las two years. The pain it is worse when walking for more than a block, exercising, and climbing stairs. Patient stated that her pain usually is 4-5 and sometimes when exacerbated can go up to 7-8 on the pain scale of 0-10. Patient also states that the pain used to be intermittent but now is constant. There is nothing that makes it better, but the cold weather makes the pain worse. Patient used to take ibuprofen for pain but stopped because GI bleed.Now takes Acetaminophen 2 tablets three times a day but it does not help. Patient reported no injury or trauma to her knees. Denies dizziness, nausea, vomit, and diarrhea.

Allergies: No known allergies.
Pertinent PMHx: Patient is up to date with his childhood immunizations.
Soc Hx: Patient denies alcohol intake, denies cigarette smoking and/or tobacco chewing. Patient Wears seat belts all the time, is not depressed.
Fam Hx: Grandparents unknown, father unknown, mother arthritis, and patient children are in good health.
History questions asked:. List out each question you asked the patient/parent. This is a focused exam unless a school or yearly physical.

Current Medications: Amlodipine 10 mg tablet once daily, Lisinopril 10 mg tablet once daily, Simvastatin 20 mg daily, hydrochlorothiazide 25 mg tablet once daily, Protonix 40 mg tablet once daily.

1. How can I help you today?
2. How severe (1-10 scale) is the pain in your knee?
3. Do your knee catch, lock?
4. Is there any stiffness in your knees?
5. Did your knees give away?

6. Is there any instability in your kness?
7. Does anything make the pain in your knees better or worse?
8. Does the pain in your knees radiate someplace else? Where?
9. Have you been having fevers?
10. Any tingling or numbness in your leg?
11. Does the pain in your knee keep you from sleeping?
12. Have you fallen before?
13. Do you have arthritis?
14. Are you able to do housework?
15. Can you tell me about any current or past medical problems you havehad?
16. Have you ever been hospitalized?
17. Do you have any allergies?
18. Are you taking any over the counter or herbal medication?
19. Are you taking steroids?
20. Are you taking any prescription medication?
21. Tell me about the health of your grandparents, parents and children?
22. Do you drink alcohol? If so, how many drinks per day?
23. Do you now or have you ever smoked or chew tobacco?
24. Do you always wear seatbelt?
25. Do you have medical insurance?
26. Have you ever had trauma of your knees?











RESPIRATORY: No shortness of breath, cough, or sputum. GASTROINTESTINAL: no nausea, vomit, or diarrhea.
GENITOURINARY: No vaginal discharge or bleeding.

NEUROLOGICAL: No headache, dizziness, syncope, paralysis, ataxia, numbness ortingling in the extremities. No change in bowel or bladder control.


MUSCULOSKELETAL: Reports bilateral knee pain as stated in HPI. HEMATOLOGIC: N/A
LYMPHATICS: N/A
PSYCHIATRIC: N/A

ENDOCRINOLOGIC: No reports of sweating, cold or heat intolerance. No polyuria orpolydipsia.

ALLERGIES: None O.
Objective:.
Physical exam: VS T 9806 F, RR 14, HR 80, BP 148/90 left arm, SPO2 94%, Hight 5’4”
(163 cm), Weight 186 lb (84.5 kg). BMI 30


General: Alert and oriented x 4, well groom female, calm and cooperative. Patient isin no apparent distress.

Cardiovascular: Neck: symmetrical, normal circumference, no scarring. Full active cervical ROM demonstrated by patient. carotid artery: normal-appearing pulsations. Thyroid: grossly WDL to inspection. No visible mass, deformity, or lymphadenopathy. Normal exam. Thyroid moves with swallowing.
Respiratory: Chest wall and lungs: chest symmetrical, normal anterior posterior (AP)diameter, normal respiratory effort and excursion. Auscultation of lungs: normal L & R. Auscultation of heart aortic pulmonic normal.
HEENT: PERRLA.

Skin: warm and dry. No jaundice, pallor, rash, or ulceration.
GI: No mass or herniation

MUSK: No asymmetry or deformity of the back. No tenderness or spasm of the paraspinal muscles. No localized tenderness of the spinous processes or pelvicstructures.

Visual inspection of extremities: bony enlargement of knees. There is evidence of a small effusion in the right knee. Some of the finger joints are enlarged proximal anddistal interphalangeal joints.