History and Physical – (Example – 1)
HPI Example: A 17 years old secondary school male student complains about left earache over the last 4 days. He consistently experiences hearing loss which is followed by an injury of the temporal side of his head. The trauma occurred when he slipped on the terrace at home four months ago. He also notes insomnia patterns, neck swelling, difficulty in concentrating on studies and weight loss. He complains that the symptoms have been causing him trouble for more than one year. The student denies having any significant medical or social history in relation to his existing problems in the past.
General Survey: The patient is awake, alert and well oriented in the space and the surroundings.
Vitals: The temperature attributes to 98.6 F; HR: 82 bpm; BP: 120/80 mm Hg; RR: 24 breaths/min.
ENT: The auricle inspected to eliminate deformities across surrounding tissues. The ear inspection is performed according to the standard techniques of moving the auricle and pressing the tragus (Bickley & Szilagyim, 2013, p. 235). The inspection of tympanic membrane with the application of speculum indicates findings attributing to normal (pearly gray) color, translucency, easy visibility of pars tensa and pars flaccid, concave contour, mobility and normal tympanic integrity. However, the abnormal findings include a yellow discoloration that indicates patterns of acute otitis media. What is more, the appearance of white patches confirms tympanosclerosis and tympanic black spot indicate eardrum perforation (Chiocca, 2010, p. 292). The appearance of scarring, vesicles and cysts further indicates tympanic bullae and cholesteatoma.
The anterior methodology for evaluating thyroid gland utilizes neutral – extension approaches under the influence of cross lightening in order to measure the dimensions of thyroid nodules. Furthermore, the anterior visualization was performed during swallowing activity with the aim to measure the upward retraction of thyroid gland. The posterior methodology focuses on tracking thyroid abnormalities and effective evaluation of the cricoids cartilage confinements, thyroid isthmus and fossa jugularis sternalis. The normal consistency of thyroid gland attributes to its rubbery texture; however, the softer, malleable and spongy thyroid indicates the existence of Grave’s disease (Braverman & Cooper, 2013, p. 323). The appearance of the enlarged and painful thyroid gland indicates the development of thyroiditis (Seidel et al., 2011, p.252). The presence of an enlarged thyroid with the bell of a stethoscope produces rushing and vascular sound that indicates its hypermetabolic state.
Investigations (Lab Tests Review): The medical tests, clinical assessment and Weber test performed in order to evaluate patient’s diagnosis prove the gross hearing evaluation (Heller & Veach, 2009, p. 287). The normal tympanogram findings attribute to the adequate vibration of eardrum retrieved under the influence of artificially induced ear pressure. The laboratory screening tests for patient’s thyroid condition according to the reported symptoms include TSH, F-T4 and F-T3. The normal level of TSH in children attributes to 0.7 – 6.4 m U/L; however in adults the normal value varies between 0.4 and 4.2 U/L (Fischbach & Dunning, 2009, p. 474). The normal values of F-T4 and F-T3 index fall between the ranges attributing to 0.7-1.9 ng/dl and 80-180 respectively.
Assessment and Plan (Clinical Findings)
This section describes the final working diagnoses obtained in relation to patient’s complaints, history and physical examination. The present clinical scenario relates to the diagnoses such as acute otitis media and thyrotoxicosis as relevant to the patient’s clinical investigation. The treatment strategies relate to the therapeutic or surgical interventions warranted for treating the patient’s clinical manifestations.
History and Physical – (Example – 2)
HPI Example: A 45 years old homemaker approaches with the complaint of fatigue, infrequent menstruation, palpitation and neck pain.
General Survey: The patient is alert, conscious and awake. Vitals recorded as normal.
ENT: The thyroid palpation with the anterior method utilizes the application of hand for retracting sternocleidomastoid muscle for examining thyroid disorders. However, the lateral method tracks the thyroid enlargement while effectively inspecting angularity between fossa jugularis sternalis and cricoid cartilage. Any prominence over and above the evaluated contour indicates the appearance of thyroid disorder. Estes (2014, p. 357) describes the thyroid inspection technique for evaluating the symmetrical movement of thyroid and isthmus as a way to track the appearance of thyroid nodules effectively. The clinical conclusion synthesized from thyroid examination attributes to the effective tracking of goiter when lateral prominence exceeds 2 mm diameter; however, the goiter is ruled out if size of recorded lateral prominence falls below 2 mm as measured by physical examination. The otoscopic examination of tympanic membrane reveals its normal structure in the absence of any perforation.
Investigations (Lab Tests Review): The lab investigations employed in screening for thyroid disorders attribute to the Total T-3 and thyroid antibodies tests. The evidence based on clinical literature reveals normal thyroglobulin antibodies (TGA) findings within the range of 1 IU/mL (Lundin, 2009, p. 192). Indeed, the elevated levels of TGA correspond to the autoimmune disorder of thyroid. The normal range for Total T-3 test attributes to 100 – 200 ng/dL. However, the Total T-3 value of > 200 ng/dL consistent with the patterns of hyperthyroidism among adult population. Muchnick (2008, p. 50) reveals the significance of anti – TPO (antithyroid peroxidase antibody) test to enhance the specificity of results, when it is performed in conjunction with TGA analysis. The normal value for anti – TPO test is less than 9.0 IU/mL, as evidenced by the research based academic literature. The tympanogram findings are tracked and revealed normal results during physical examination. Indeed, the normal tympanometry values for adults attribute to 1.1 cc (for mean ear canal volume) and 0.8 cc (for mean peak compliance) respectively.
Assessment and Plan (Clinical Findings)
The clinical assessment proceeds in accordance with the patient’s age, clinical history, physical exam findings and review of lab results. The probable diagnoses include hyperthyroidism, thyroid nodules, hypothyroidism or thyroid malignancy retrieved from the clinical assessment which require appropriate therapeutic or surgical interventions in order to initiate effective treatment.
Bickley, L., & Szilagyim, P.G. (2013). Bates’ Guide to Physical Examination and History-Taking (11th ed). Philadelphia: Wolters Kluwer| Lippincott.
Braverman, L.E., & Cooper, D. (2013). Werner & Ingbar’s The Thyroid: A Fundamental and Clinical Text (10th ed). Philadelphia: Wolters Kluwer| Lippincott.
Chiocca, E.M. (2010). Advanced Pediatric Assessment. Philadelphia: LWW.
Estes, M.E. (2014). Health Assessment and Physical Examination. New York: Cengage.
Fischbach, F.T., & Dunning, M.B. (2009). A Manual of Laboratory and Diagnostic Tests (8th ed). Philadelphia: Wolters Kluwer| Lippincott.
Heller, M.E., & Veach, L.M. (2009). Clinical Medical Assisting: A Professional, Field Smart Approach to the Workplace. New York: Delmar – Cengage.
Muchnick, B.G. (2008). Clinical Medicine in Optometric Practice. Missouri: Mosby – Elsevier.
Seidel, H.M., Ball, J.W., Dains, J.E., Flynn, J.A., Solomon, B.S., & Stewart, R.W. (2011). Mosby’s Guide to Physical Examination (7th ed). Missouri: Mosby – Elsevier.