Situation: 27 year old male patient presented for wellness visit. Patient denied diarrhea, nausea, vomiting, pain, food intolerances, change of appetite, unexplained weight loss, and difficulty swallowing. Patients last BM was yesterday afternoon and described it as medium, soft and brown. Patient is not taking any prescription medication. He has no Hx of peptic or gastric ulcers, appendicitis, colitis, hernias, surgical procedures, jaundice, diverticulitis, AAA, cancer, Crohn’s Disease. Patient does not have a family Hx of cancer, or Crohn’s Disease.
Objective: Patient presented with benign facial expression and is breathing slow and even without struggling. No involuntary body movements. No structural abnormalities, all limbs intact. Face is symmetrical. Posture is upright when sitting. Abdomen contour is round, symmetrical bilaterally with no bulging or visible mass. Umbilicus is midline with no signs of discoloration, inflammation, piercing, or hernia. Skin is clean, dry, intact and appropriate color with ethnicity. I was not able to observe pulsation of the aorta. Vitals were as follows, BP: 122/58 LA, sitting, HR: 60 (radial), SaO2: 99% RA, RR: 13, and no pain.
Assessment:
Abdomen: Positive hyperactive BS x4 upon auscultation. Tympani throughout 4 quadrants upon percussion. Palpation revealed no tenderness, mass, bulges. No abnormal enlargement of liver upon palpation of RUQ. Could not palpate aortic pulse. Negative fluid wave test.
HEETN: Normocephalic, no lumps, depressions, abnormal protrusions. TMJ smooth movement with no limitations or tenderness. Symmetry of eyebrows, nasolabial folds and sides of mouth. No lymphadenopathy/thyroidmegaly detected. Full range of motion, 5+ muscle strength. PEERLA. Negative JVD. Trachea in straight alignment. Hair evenly distributed. Ears symmetrical, no deformities observed.
Skin: Warm, smooth, firm and dry with even surface upon palpation. Skin intact, no signs of bruising or lesions. No signs of edema, cyanosis, erythema or pallor. No acne or nevi present on face. No signs of decreased skin turgor upon palpation.
Respiratory: Even expansion of chest upon palpation. Resonance sounds of lungs throughout. Upon auscultation, no wheezing or crackling. Anterior-Posterior diameter less than 1:2. No lumps/masses detected upon palpation during patient deep inspiration. No crackles, rails, wheezing, or popping detected upon auscultation.
Cardio: No thrills upon palpation. S1 S2 detected in normal rhythm and S3S4 absent. No murmurs or arrhythmias found when auscultating aortic, pulmonic, Erb’s point, tricuspid and mitral areas. Negative JVD. All pulses found upon palpation with 2+ grade. Carotid pulse normal and 2+ grade. Non-bounding upon palpation over chest between 2nd and 5th intercostal space on left sternal border.
Plan: Encourage patient to engage in cardio exercises for 45 minutes 3 times a week. Educate the patient about eating less saturated fat and simple carbohydrates. Encourage the patient to eat at least 4 servings of vegetables and 2 servings of fruit every day. Educate the patient about the sugar contents and health effects of over-consumption of soft-drinks. Educate the patient about substance abuse and the effects of smoking.
Health Science 