A Physical Examination and Histories
The main complaint is: I am constantly thirsty.
Histories: The complaint presentation was made by Ms. X. She is a 27 year-old African American woman who has been a customer at the clinic for many years. These symptoms are alleged to have occurred for one month. Her mother tried to quench her thirst by using cold and soft debunks but it was in vain. Her thirst continues to resurface even though she has ingested copious amounts water. Little exertion can intensify her thirst. Because of this increased thirst and urgency, she can’t do daily tasks flawlessly.
Analyse of Systems
Overall, Her protruding belly is a sign she’s pregnant.
Eyes/heads: May cause vision impairment, discomfort in the eyes, or headaches occasionally
ENT is a diagnosis that denies the presence of a sore or rhinorhoea.
Cardiovascular: Denial of Chet discomfort, dyspnea and shortness of breathe
Refuses to admit nausea or vomiting. Reports heartburn, excessive appetite occasionally
Genitourinary discomfort during the past twelve hours. On a scale from one to ten, pain is scored as a 4.
Pregnancy details: LMP-December 20, 2021, EDD: September 27, 2022
This is a way to deny discomfort, joint pain and tingling.
Neurological: Does not acknowledge changes in sight, taste or hearing.
Refrain from causing any skin lacerations or rash.
Psychiatric includes denial of any history or anxiety.
Endocrine: She confirms the presence of polyuria as well as polydipsia. She denied ever having experienced cold intolerance.
Hematologic: Stops bleeding and bruising.
Allergy testing: Denies all allergies
Appendicectomy: A review of medical and surgical history
There are no pharmacological or environmental allergies.
Current medication: two multivitamin pills per day
Father is healthy and is well. His diabetes is being managed. Mother is well and healthy. A brother recently diagnosed with type 2 diabetes has decided to abandon the prescribed regimen.
Use of cigarettes and other recreational drugs can be impeded by social history.
The body is to be examined
Vitals: BP- 123/75mmHg, Temperature: 36.6℃, Pulse: 76 beats per minute, Respirations: 22 beats per minute
Strong sense of location and time. She is well-groomed and shows no signs of anxiety. Health as measured by age
HEENT: Pupils are equal, spherical, and light and accommodation-responsive; oropharynx is clear; no erythema or lymphadenopathy is noted.
Respiratory: Symmetrical chest extensions
Cardiac: S1 audible and S2 audible
Extremities: Symmetrical joints. No cyanosis.
Neurologically all cerebellar functions and cranial nerves remain intact.
Musculoskeletal: No skin rashes and excellent skin turgor
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