Introduction
Beverly describes herself and her pain.
Interview Beverly
Chief Complaint
Beverly describes her chief complaint.
What Makes the Pain Better
Beverly describes what alleviates her pain.
Description of Pain
Beverly describes her pain more in depth.
What Makes the Pain Worse
Beverly describes what aggravates her pain.
Location of Pain
Beverly describes where she feels her pain.
Pain Duration
Beverly states she's experienced her pain for at least a year.
Beverly's Review of Systems
General
In general, Beverly has experienced no weight loss, fatigue, or fever.
CNS/Neuro
Beverly has experienced the following:
- no visual changes
- no confusion
- no loss of consciousness
- presence of anxiety
- presence of headaches
- presence of photophobia, or sensitivity to light
- presence of phonophobia, or sensitivity to sound
- no aura, or visual disturbance
Cardiovascular/Pulmonary
Beverly has experienced the following:
- no chest pain
- no shortness of breath
- no cough
- presence of heart palpitations
Gastrointestinal/Genitourinary
Beverly has experienced the following:
- no nausea or vomiting
- no constipation or diarrhea
- no melena
- no hematochezia
- no hematemesis
- no urinary frequency abnormalities, urinary urgency, urinary retention, or incontinence
Musculoskeletal/Extremities
Beverly has experienced the following:
- no swelling
- no weakness
Beverly's Labs and Tests
Beverly’s labs and tests reveal the following:
- Sodium level is 136 mmol/L. Normal range for females is 135-146 mmol/L.
- Potassium level is 4.0 mmol/L. Normal range for females is 3.5-5.3 mmol/L.
- Chloride level is 100 mmol/L. Normal range for females is 98-110 mmol/L.
- Carbon dioxide level is 30 mmol/L. Normal range for females is 19-30 mmol/L.
- Blood urea nitrogen level is 12 mg/dL. Normal range for females is 7-20 mg/dL.
- Serum creatine level is 0.87 mg/dL. Normal range for females is 0.6-1.2 mg/dL.
- Calcium level is 9.9 mg/dL. Normal range for females is 8.8-10.4 mg/dL.
- Albumin level is 4/3 g/dL. Normal range for females is 3.6-5/1 g/dL.
- Bilirubin (total) level is 0.8 mg/dL. Normal range for females is 0.2-1.2 mg/dL.
- Alkaline phosphatase level is 95 U/L. Normal range for females is 33-115 U/L.
- Aspartate aminotransferase level is 25 U/L. Normal range for females is 10-40 U/L.
- Alanine aminotransferase level is 31 U/L. Normal range for females is 7-35 U/L.
Beverly has had a CT without contrast that showed negative within the previous thirty days.
Beverly's Medications
Beverly has no known drug allergies.
She currently takes the following medication:
- Acetaminophen, 500 mg tables sig. 1 tab every four to six hours as needed. Click here to learn more about this medication: http://www.fda.gov/Drugs/DrugSafety/InformationbyDrugClass/ucm165107.htm
- Citalopram 20 mg tablets sig. 1 tab every morning. Click here to learn more about this medication: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4204633/
- Hydroxyzine HCl 25 mg tablets sig. 1 tab every six hours as needed. Click here to learn more about this medication: https://pubchem.ncbi.nlm.nih.gov/compound/Hydroxyzine
Beverly's Physical Exam
In general, Beverly is alert and oriented to person, place, and time. Her affect and speech is appropriate.
Head, Eyes, Ears, Nose, and Throat examinations reveal the following:
- pupils equal, round, and reactive to light and accommodation (PERRLA)
- conjunctiva anicteric
- hyperopia corrected with glasses
- no lymphadenopathy
Cardiovascular/Pulmonary examinations reveal the following:
- no crackles, rales, rhonchi, or wheezes in the lungs
- regular heart rate and rhythm with no murmurs, gallops, or rubs
Gastrointestinal/Genitourinary examinations reveal the following:
- positive bowel sounds in all four quadrants
Extremities/CNS/Musculoskeletal examinations reveal the following:
- no cyanosis, edema, or jaundice
- normal strength and range of motion bilaterally
- normal deep tendon flexes bilaterally