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Chief Complaint • The chief complaint is a brief statement of the reason why the patient consulted the physician, stated in the patient’s own words. In order to convey the patient’s symptoms accurately, medical terms and diagnoses are generally not used. The appropriate medical terminology is used after an appropriate evaluation (i.e., medical history, physical examination, laboratory and other testing) leads to a medical diagnosis.
Chief Complaint • “My gynecologist said I should have a check-up since I am tired all the time.”
HPI • The history of present illness is a more complete description of the patient’s symptom(s). Usually included in the HPI are: • Date of onset • Precise location • Nature of onset, severity, and duration • Presence of exacerbations and remissions • Effect of any treatment given • Relationship to other symptoms, bodily functions, or activities (e.g., activity, meals) • Degree of interference with daily activities
HPI • Louise Jackson is a 49-year-old woman who presents to her primary care physician after her gynecologist recently diagnosed her with polycystic ovarian syndrome (PCOS) during an evaluation for amenorrhea. • She complains of increasing fatigue, which she attributes to being overweight. She states her last appointment with her PCP was over 2 years ago.
PMH • The past medical history includes serious illnesses, surgical procedures, and injuries the patient has experienced previously. Minor complaints (e.g., influenza, colds) are usually omitted unless they might have a bearing on the current medical situation.
PMH • PCOS × 2 months • Hyperlipidemia × 2 years (diet controlled) • HTN × 4 years
FH • The family history includes the age and health of parents, siblings, and children. For deceased relatives, the age and cause of death are recorded. In particular, heritable diseases and those with a hereditary tendency are noted (e.g., diabetes mellitus, cardiovascular disease, malignancy, rheumatoid arthritis, obesity).
FH • Diabetes present in both mother and maternal grandmother. Father died suddenly of colon cancer at age 59, mother alive age 76 with history positive for DM Type 2, HTN, and hyperlipidemia; one younger sister with PCOS and HTN.
SH • The social history includes the social characteristics of the patient as well as the environmental factors and behaviors that may contribute to the development of disease. Items that may be listed are the patient’s marital status; number of children; educational background; occupation; physical activity; hobbies; dietary habits; and use of tobacco, alcohol, or other drugs.
SH • Married × 23 years with two children. Works full-time as insurance consultant which is telephone based from home. No alcohol or tobacco use. Rarely exercises and admits to trying fad diets for weight loss with little success. She reports adherence to her medications.
Meds: • The medication history should include an accurate record of the patient’s current use of prescription medications, nonprescription products, and dietary supplements. Because pharmacists possess extensive knowledge of the thousands of prescription and nonprescription products available, they can perform a valuable service to the health care team by obtaining a complete medication history that includes the names, doses, routes of administration, schedules, and duration of therapy for all medications, including dietary supplements and other alternative therapies.
Meds: • Ortho-Novum 1/35 as directed • Hydrochlorothiazide 50 mg po daily
ALL: • Allergies to drugs, food, pets, and environmental factors (e.g., grass, dust, pollen) are recorded. An accurate description of the reaction that occurred should also be included. Care should be taken to distinguish adverse drug effects (“upset stomach”) from true allergies (“hives”).
All • Codeine
ROS • In the review of systems, the examiner questions the patient about the presence of symptoms related to each body system. In many cases, only the pertinent positive and negative findings are recorded. In a complete ROS, body systems are generally listed by starting from the head and working toward the feet and may include the skin, head, eyes, ears, nose, mouth and throat, neck, cardiovascular, respiratory, gastrointestinal, genitourinary, endocrine, musculoskeletal, and neuropsychiatric systems.
The purpose of the ROS is to evaluate the status of each body system and to prevent the omission of pertinent information. Information that was included in the HPI is generally not repeated in the ROS.
ROS • Frequent fatigue. Occasional polydipsia, polyphagia, weakness, and lightheadedness upon standing. Denies blurred vision, chest pain, dyspnea, tachycardia, dizziness, or tingling or numbness in extremities, leg cramps, peripheral edema, changes in bowel movements, GI bloating or pain, nausea or vomiting, urinary incontinence, or presence of skin lesions.
Physical Examination • The exact procedures performed during the physical examination vary depending upon the chief complaint and the patient’s medical history. In some practice settings, only a limited and focused physical examination is performed. In psychiatric practice, greater emphasis is usually placed on the type and severity of the patient’s symptoms than on physical findings. A suitable physical assessment textbook should be consulted for the specific procedures that may be conducted for each body system. The general sections for the PE are outlined as follows:
Gen (general appearance) • VS (vital signs)—blood pressure, pulse, respiratory rate, and temperature. • In hospital settings, the presence and severity of pain is included as “the fifth vital sign, weight and height are included in the vital signs section here, but they are not technically considered to be vital signs. • Skin (integumentary)
HEENT (head, eyes, ears, nose, and throat) • Lungs/Thorax (pulmonary) • Cor or CV (cardiovascular) • Abd (abdomen) • Genit/Rect (genitalia/rectal) • MS/Ext (musculoskeletal and extremities) • Neuro (neurologic)
Gen: • Patient is an African-American woman with central obesity in no apparent distress
VS • BP 152/88 sitting R arm, BP 130/70 standing R arm, P 82, RR 18, T 37.2°C; Wt 95.5 kg, Ht 5'6'‘ • BP = Blood Pressure. • HR = Heart rate. • Bpm = beat per minute. • RR = Respiratory rate. • T = Temperature. • Wt = Weigt • Ht= Hight
Skin • Dry with poor skin turgor; no ulcers or rash
HEENT • PERRLA; EOMI; TMs intact; no hemorrhages or exudates on funduscopicexamination; mucous membranes normal; nose and throat clear w/o exudates or lesions • PERRLA = Pupils equal, round, and reactive to light and accommodation • EOMI = Extraocular movements (or muscles) intact • TM = Tympanic membrane.
Neck/Lymph Nodes • Supple; without lymphadenopathy, thyromegaly, or JVD Lungs: • CTA = Clear To Auscultation
CV: • RRR; normal S1 and S2; no S3, S4, rubs, murmurs, or bruits • RRR = Regular rate and rhythm. • S = Sound.
Abd: • Soft, NT, central obesity; normal BS; no organomegaly, or distention. • NT / ND = Non-tender/non-distended. • BS = Bowel sounds; breath sounds or blood sugar
Genit/Rect: • Deferred Ext: • Normal ROM and sensation; peripheral pulses 2+ throughout; no lesions, ulcers, or edema • ROM = Range of motion
Neuro: • A & O × 3, CN II–XII intact; DTRs 2+ throughout; feet with normal vibratory and pinprick sensation (5.07/10 g monofilament) • CN II–XII = Cranial Nerves 2 to 12. • A & O × 3 = Awake and oriented to person, place, and time. • DTR = Deep-tendon reflex
UA: • (–) ketones, (–) protein, (–) microalbuminuria
Assessment: • Elevated random glucose; presumed newly diagnosed Type 2 diabetes mellitus; will obtain a fasting blood glucose level to confirm the diagnosis and also check A1C • Elevated total cholesterol; will obtain fasting lipid profile to evaluate LDL, HDL, and triglycerides • Hypertension with suboptimal treatment and possible side effects due to diuretic • Obesity • PCOS
Clinical Course • The patient returned to clinic 3 days later for lab work, which revealed: FBG 189 mg/dL; A1C 9.4%; FLP: T. chol 263 mg/dL, HDL 31 mg/dL, LDL 152 mg/dL, Trig 260 mg/dL.
Problem Identification • 1.a. What risk factors for Type 2 DM are present in this patient?
Problem Identification • 1.b. What information (signs, symptoms, laboratory values) supports the diagnosis of Type 2 DM?
Problem Identification • 1.c. What information indicates the presence of insulin resistance?
Problem Identification • 1.d. Create a list of this patient’s drug therapy problems.
Desired Outcome • 2.a. What are the desired goals for the treatment of this patient’s diabetes?
Desired Outcome • 2.b. Considering her other medical problems, what other treatment goals should be established?
Therapeutic Alternatives • 3.a. What nonpharmacologic therapies might be useful in the management of this patient?
Therapeutic Alternatives • 3.b. What feasible pharmacotherapeutic alternatives are available for the treatment of this patient’s DM? Identify the factors that will influence your choice of initial therapy.
Optimal Plan • 4.a. Outline a complete pharmacotherapeutic plan to manage this patient’s current problems, including drug, dosage form, dose, schedule, and rationale for your selections. • 4.b. What changes in therapy would you recommend if your initial plan fails to achieve adequate glycemic control?
Outcome Evaluation • 5.a. What clinical and laboratory parameters will you monitor to evaluate glycemic efficacy and to detect or prevent adverse effects?
Outcome Evaluation • 5.b. The patient’s physician suggested that she obtain a blood glucose meter for self-testing. What are the health care provider’s responsibilities with respect to patients and self-monitoring of blood glucose (SMBG)?
Outcome Evaluation • 5.c. Identify at least four potential situations in which the information provided by SMBG would be useful to patients and health care providers.
Outcome Evaluation • 5.d. What factors should be considered in the selection of an appropriate blood glucose meter?
Patient Education • 6.a. What information should be provided to the patient about diabetes and its treatment to enhance compliance, ensure successful therapy, minimize adverse effects, and prevent future complications?
Patient Education • 6.b. How would you educate the patient regarding how and when to check her blood glucose?
Follow-up Questions • 1. Which over-the-counter products could be recommended for patients to use in treating hypoglycemic episodes? • 2. List several potential sources of error in SMBG.
