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Northern Kentucky University MSN 610: Diagnostic Reasoning and Advanced Physical Assessment Comprehensive History & Physical Exam DEMOGRAPHICS Providers Name: Student NP Patient’s Initials: (Data Source ) DC Date of Exam: 16/202 5 Patient’s DOB/AGE: 10/08/1988 35 Chief Complaint: Insomnia Gender/Sexual Orientation : _Male/Heterosexual History of Present Illness: The patient is a 35 - year-old Caucasian male who had trouble sleeping over the last few weeks. He states he has difficulty falling asleep and staying asleep, especially during the work week. The patient has a history of Hyperlipidemia and denies any other pre-existing conditions, illnesses, or symptoms that prompted this visit. The patient states he does have seasonal allergies. Past Medical History: Active Problems : Hyperlipidemia, Dehydration, Seasonal Allergies, Insomnia Resolved Problems / Childhood illnesses: Unknown Previous Hospitalizations/Accidents/Injuries: The patient states he broke his left pinky at 16 years old playing football. Surgical History: The patient denies any previous surgical history. Allergies: The patient reports seasonal allergies and no known food or medication allergies. Current Medications (including OTC) : One-a-day men’s vitamin one tablet PO daily, last taken was this morning. Triple Omega fish oil is one capsule PO daily; the last taken was this morning. Zyrtec as needed for seasonal allergies one tablet PO daily as needed; last taken was two days ago. Atorvastatin 20mg, one tablet PO daily; last taken was last night. Social History : Living Arrangements: The patient lives in a two-story home with his wife and child. Marital Status/children: Married with one child who is four years old and autistic. Occupation/Education: Doctorate in pharmacy
Environmental Safety : The patient states his house has smoke and carbon dioxide detectors, a fire extinguisher, and a fire escape plan for his house. The patient reports no exposure to hazardous drugs/chemicals at work or home and adheres to all safety protocols in the workplace. The patient reports wearing his seatbelt and does not text and drive. Smoking: Denies ever smoking. Alcohol: The patient reports occasional alcohol consumption after work on Fridays. The patient reports drinking 2 oz glasses of bourbon. The patient reports typically drinking 2-3 glasses on Fridays. Drugs: Denies any illicit drug use Diet: The patient reports trying to follow a low-fat diet due to his recently diagnosed high cholesterol. Caffeine intake: The patient reports increased caffeine intake and drinking 2 - 3 cups of coffee in the mornings and 1-2 sodas in the afternoon. His total caffeine intake is around 200-300mg. Lifestyle/Activity level : As of two weeks ago, the patient reports being more active and starting to go to the gym 2-3 times a week for at least an hour. The patient also reports golfing most weekends to de-stress from work. Hobbies / Sports / Leisure activities: The patient reports golfing on the weekends. Other Non-Prescribed Drugs: Patient states taking OTC Zyrtec, omega 3, and a men's multivitamin. Family History: Relationship Living^ or Deceased Age Illnesses Mother Living 62 Hypothyroidism Father Living 65 Unknown Paternal Father Deceased 88 Hypertension, Hyperlipidemia Paternal Mother Deceased 86 Unknown Maternal Father Deceased 83 Unknown Maternal Mother Deceased 52 Unknown Preventative Health/ Anticipatory Guidance: (Age Appropriate)
- Safety Issues: The patient stated he does not see the doctor regularly; his first primary care appointment was last year. The patient was educated on the importance of preventative checks and yearly doctor visits. He wears a seatbelt when driving. There are active smoke detectors in his home and office.
history of trauma/surgeries, or back pain. The patient reported breaking his left pinky when he was 16 playing football. The patient denies any family history of musculoskeletal diseases or disorders. Neuro: The patient denies any dizziness, headaches, syncope/near-syncope, paralysis, paresthesia, history of LOC, history of seizures, history of loss of bowel or bladder control, or loss of memory. The patient also reported a change in the amount of sleep he gets, stating it’s due to the stress of a new job and an increased caffeine intake. Endo/Lymphatic: The patient denies any polyphagia (increase in thirst), polyuria (increase in urination), goiter, lethargy, hot/cold intolerance, nervousness, change in sex characteristics, gynecomastia, or flushing. The patient also denies any enlarged lymph nodes. The patient is overweight. Hematology: The patient denied an issue of blood disorder or issues. The patient stated there is no family history of blood disorders or cancer and denied bruising or being easily injured. Psych: Patient denies any current anxiety, depression, hallucinations, suicidal or homicidal ideation, history of involuntary commitment, or delusions. The patient states he does have some stress related to his new position at work. Physical Exam Vital Signs: Temp: 98.4 Pulse: _ 100% on RA BP: 124 / 82 Resp: 16 O2 sat:
- General: DC is a pleasant 35-year-old Caucasian male who presents to the clinic with insomnia complaints. He appears well-nourished and well-developed and is dressed appropriately with good hygiene. He is alert and oriented to person, time, place, and situation. His speech is clear, coherent, and organized. He maintained eye contact throughout the interview and followed directions. He is seated upright in the chair and shows no apparent sign of distress. His skin color is appropriate for his ethnicity and warm to the touch. He is here today to find the underlying cause of his insomnia.
- Head: DC’s head is normocephalic and atraumatic. The head is symmetric, with no masses, indentations, or lesions felt. Hair was evenly distributed in the back with no patches noted; however, he showed signs of balding and hair thinning in the front and top of his head. The hair is fine and smooth. No neck stiffness or photophobia. No meningeal signs.
- Ears: DC’s ear shape is equal bilaterally and symmetrical—no pain when palpating the auricles and pinas. External ear canals are without inflammation, redness, or drainage bilaterally. Tympanic membranes are pearly grey in color, shiny, and translucent with no bulging or retraction bilaterally. Rinne (air conduction is better than bone conduction) bilaterally, Weber (tone is heard equally on both sides) bilaterally, and Whisper test positive bilaterally, so cranial nerve 8 (Vestibulocochlear) is intact.
- Eyes: DC’s eyes are appropriately placed on the face and midline to the ears; they are symmetrical with equal hair distribution across eyebrows and eyelashes bilaterally—no crustation of lashes or eyebrows bilaterally. No lesions, ptosis, or edema were noted bilaterally. The conjunctiva is pink and moist, with no signs of bilateral conjunctivitis. The sclera is white bilaterally. Extraocular movements are intact bilaterally, and the peripheral sight is intact bilaterally (Testing Cranial Nerve 3,4,6- Oculomotor, Trochlear, and Abducens). The pupils are equal, round, and reactive to light and accommodation bilaterally. Red Reflex visualized bilaterally; the disc is visualized as yellowish, with sharp margins noted bilaterally. The cupping margins are appropriate in size bilaterally, and the vessels have no vascular changes or signs of hemorrhaging bilaterally. Direct pupil response and accommodation were
present bilaterally (Testing cranial never 2 - optic nerve). Eyes converge appropriately. Vision is 20/20 in the left eye and 20/20 in the right eye. A confrontation test was performed with no abnormal findings; the patient's peripheral vision is intact bilaterally.
- Nose: DC’s nose is straight and midline on the face. No septal deviation was present; nasal mucosa is pink and moist; turbinates are intact, with no lesions present bilaterally. Bilateral nares are patent—no pain with palpation of frontal, ethmoid, or maxillary sinuses. No hemorrhaging is present bilaterally. CN 1 (olfactory) is intact, patient was able to identify two different smells with each nostril.
- Throat: DC’s buccal mucosa is pink and moist; no lesions, ulcerations, or wounds are visualized. The uvula is midline and moved up and down appropriately when saying “ah.” The anteroposterior pillars were visualized and were pink and moist, with no discoloration noted. Tonsils were present and symmetrical, and no swelling was noted bilaterally. The oropharynx is pink, and no discoloration or swelling was noted. Teeth are intact, with no cracks or chipping on the teeth, and gums are pink with no bleeding noted. Soft and hard palates were visualized, and no lesions were visualized or palpated. TMJ was assessed, and there were no clicks or pain but a full range of motion. The lips are pink and intact, with some dryness. The mouth was free of odor.
- Neck: DC’s neck is symmetrical and flexible with no signs of decreased ROM; the trachea is midline. The skin is smooth with no discoloration. The thyroid is smooth without nodules or goiter, and no bruits are heard bilaterally. The preauricular, postauricular, occipital, tonsillar, submandibular, submental, anterior cervical, posterior cervical, deep cervical, supraclavicular, and infraclavicular lymph nodes are non-tender and mobile bilaterally, no pain or tenderness, no nodules felt during palpation exam. No JVD present.
- Heart: DC’s heart rate is regular at 72 bpm, S1, S2 heard, without murmurs, gallops, or rubs. Bilateral carotids +2 equal bilaterally without bruit noted. PMI at the midclavicular line, 5th intercostal space, no heaves, lifts, or thrills present. Bilateral radial pulses present 2+ and equal bilaterally, capillary refill less than 3 seconds. No peripheral edema was noted. Aortic- 2nd right intercostal space, pulmonic- 2nd left intercostal space, Erbs point-3rd left intercostal space, Tricuspid- 4th left intercostal space and Mitral- 5th left intercostal space.
- Lungs: DC’s chest is symmetric with respiration and no deformity, clear to auscultation bilaterally without cough or adventitious breath sounds anteriorly and posteriorly. Resonant to percussion throughout. Easy, even, unlabored, and regular respiratory movements were observed—no use of accessory muscles or shortness of breath. The patient does not appear to be in respiratory distress or pain upon inspiration or expiration. No adventitious breath sounds were heard—no paradoxical movement. No crepitus upon palpation. The Tactile Fremitus test had equal and moderate vibrations when saying "99". The egophony test is complete; no consolidation was noted anteriorly, posteriorly, or bilaterally.
- Abdomen : DC’s abdomen is rounded and symmetric, with no visible masses, scars, hernias, or lesions. A small bruise about 2 cm in diameter on the RLQ from a previous injection site: no distention was noted, and coarse hair is present from the pubis to the umbilicus. Bowel sounds are normoactive in all four quadrants without guarding, tenderness, or rebound pain to palpation. Tympany is heard throughout the abdomen to percussion. The liver is in the right upper quadrant and measures 9 cm in span, below the right costal margin, and the upper border is identified at the 5th intercostal space at the MCL with dullness on percussion. No hepatomegaly. The gallbladder cannot be palpated—Murphy's sign is negative. The spleen and kidneys are not palpable, and there is no dullness on percussion. No organomegaly. No CVA tenderness. No bruits were heard bilaterally in the femoral, renal, and iliac arteries.
c. Cognitive Function: Cognition intact with the mini cognitive exam. The patient is alert and orientated to the person, place, time, and situation. The patient accurately stated his telephone number, age, date of birth, and current US president. The patient correctly identified three words given immediately after (Red, White, and Blue) and recalled the same three words later. The patient accurately stated numbers serial 7s back from 100. Patient able to accurately draw a clock put the numbers in a circle, and then correctly "set the time" to 3: Assessment Statement: A 35-year-old Caucasian male presents to the clinic with a new onset of insomnia. The patient is noted to have a history of hyperlipidemia. The patient states he has been told that his cholesterol has been high previously but stated he did start the new diet recommended last month. The patient also states that his diet is not very consistent due to a new job and stress. I have encouraged the patient to start a low-fat diet, eat healthy fats, and promote less fast-food intake. Additionally, I educated the patient that an adult should ideally get 150 minutes of aerobic exercise a week. The patient is encouraged to walk for 20 minutes daily and slowly increase the time and pace. I educated the patient on risk factors associated with obesity, such as an increased risk of diabetes, hypertension, and heart disease. Additionally, I recommend decreasing caffeine intake to half of his usual 200-300mg; both can impact sleep. Furthermore, I educated him on increasing his fluid intake, specifically water or drinks with electrolytes, to help rehydrate his skin. Recommend follow-up in 2 - 3 weeks. Problem List (Minimum of 3 required) Include ICD – 10 codes
- Hyperlipidemia (E 78.49)
- Insomnia (F15.282)
- Seasonal allergies- rhinitis (J30.2) Plan:
- Continue with daily atorvastatin 20mg PO as prescribed by the previous doctor and will continue to monitor laboratory lipid panel levels in 3 months.
- Decrease caffeine intake by half. Limit sodas, coffee, tea, and other drinks that may contain caffeine. The goal is to consume no more than 150mg a day.
- Continue current allergy medications for seasonal allergies; will monitor and make changes to allergy medication if needed.
- Keep a sleep diary to track sleeping patterns, wake times, and any factors affecting your sleep. Bring in with the next visit. Submitted by: Student NP Date: 16/202 5
