History and Physical Notes
Date of Admission
August 6, 2014
Patient Initials
B.K.
Age/Gender
74/Female
Date of Birth
11/29/ 1940
Chief Complaint
Swollen and painful legs and feet; shortness of breath.
Symptoms
Unable to be on her feet for very long; cannot walk long distances; hard time climbing stairs.
History of Present Illness
Mrs. B.K is a 73 year old Caucasian female presented with edema to both legs and feet, which she’s had for the past 12 years. Patient stated the pain is aggravated when she walks more than 10 minutes; she is forced to take short breaks when doing household chores. Pain level 7/10. Relieved by elevating her legs on a pillow and hot showers or foot baths. Adheres to medications on a daily basis to aid …show more content…
Hypertension present in the family; mother died at 76 years old
2. Diabetes present in the family; B.K. was diagnosed with type II (2000)
3. Stroke (embolic) present in the family; brother H.M. died at 86 years old
4. Heart attacks present in the family; father died at age of 72 years old; brother M.M. died at 71 years old
5. Stenosis present in the family; Brother J.M. died at 85 years old and B.K. was recently diagnosed with early stages of aortic stenosis and mitral valve stenosis.
72, Father, 76, Mother, Heart attack Stroke due to high BP
86, 85, CHF 71, heart attack 82, well 80, well 73, patient, Stroke, Painful swollen legs Meningitis …show more content…
stated “I rarely have headaches or have dizziness”
Mental Status
B.K. has very good reading and calculating comprehension; she has not had any memory changes or mood changes.
Eyes
B.K. wears reading glasses, hyperopia; she does not have blurred vision or double vision
Speech
B.K. does not have any speech conditions
Motor
B.K. cannot walk longer than 10-15 minutes due to her leg pain.
B.K’s balance is good and coordination is fair.
Constitutional
On occasion, B.K. feels tired and feels low on energy. When she rests, she feels better. Denies anorexia and weight loss.
Objective Data
Height: 5’0”
Weight: 265 lbs.
BMI: 51.6
Vital signs
Temperature: 98.9o F, oral
Blood Pressure: Right arm: 130/70 (Large adult size cuff, sitting down).
Pulse: 78, radial
Respiration: 20, unlabored
Oxygen saturation: 99%
Pain: 6-7 (0 = no pain / 10 = worst pain they have experienced)
General appearance
Appropriately dressed, well-groomed Caucasian female; good steady eye contact; happy and pleasant
Date of Admission
August 6, 2014
Patient Initials
B.K.
Age/Gender
74/Female
Date of Birth
11/29/ 1940
Chief Complaint
Swollen and painful legs and feet; shortness of breath.
Symptoms
Unable to be on her feet for very long; cannot walk long distances; hard time climbing stairs.
History of Present Illness
Mrs. B.K is a 73 year old Caucasian female presented with edema to both legs and feet, which she’s had for the past 12 years. Patient stated the pain is aggravated when she walks more than 10 minutes; she is forced to take short breaks when doing household chores. Pain level 7/10. Relieved by elevating her legs on a pillow and hot showers or foot baths. Adheres to medications on a daily basis to aid …show more content…
Hypertension present in the family; mother died at 76 years old
2. Diabetes present in the family; B.K. was diagnosed with type II (2000)
3. Stroke (embolic) present in the family; brother H.M. died at 86 years old
4. Heart attacks present in the family; father died at age of 72 years old; brother M.M. died at 71 years old
5. Stenosis present in the family; Brother J.M. died at 85 years old and B.K. was recently diagnosed with early stages of aortic stenosis and mitral valve stenosis.
72, Father, 76, Mother, Heart attack Stroke due to high BP
86, 85, CHF 71, heart attack 82, well 80, well 73, patient, Stroke, Painful swollen legs Meningitis …show more content…
stated “I rarely have headaches or have dizziness”
Mental Status
B.K. has very good reading and calculating comprehension; she has not had any memory changes or mood changes.
Eyes
B.K. wears reading glasses, hyperopia; she does not have blurred vision or double vision
Speech
B.K. does not have any speech conditions
Motor
B.K. cannot walk longer than 10-15 minutes due to her leg pain.
B.K’s balance is good and coordination is fair.
Constitutional
On occasion, B.K. feels tired and feels low on energy. When she rests, she feels better. Denies anorexia and weight loss.
Objective Data
Height: 5’0”
Weight: 265 lbs.
BMI: 51.6
Vital signs
Temperature: 98.9o F, oral
Blood Pressure: Right arm: 130/70 (Large adult size cuff, sitting down).
Pulse: 78, radial
Respiration: 20, unlabored
Oxygen saturation: 99%
Pain: 6-7 (0 = no pain / 10 = worst pain they have experienced)
General appearance
Appropriately dressed, well-groomed Caucasian female; good steady eye contact; happy and pleasant