I Human Week 3: Hailey Richardson Graves’ Disease
Verified Study Solutions Rated A+
Reason for Encounter: Trouble sleeping
5'5" 126 lb
A&Ox4
99F
102 pulse
BP L 130/72; R 128/72 PP normal
RR 14
SpO2 94%
Last Visit: 1 year 1 month ago. Vision normal. Occasional GERD. Chronic Constipation, uses Metamucil,
coffee, exercise; Completes SBE; Denies depression; Normal endocrine;
No meds prescribed; Multi-Vitamin, Calcium daily
History: HPI
HR is a 65yo female who presents to the office with c/o sleeping difficulties. She reports intermittent
sleep issues for a couple of months but it has gotten progressively worse over the last week or so. She
describes difficulties falling asleep and staying asleep, as well as being very fatigued throughout the day.
Simultaneously, she feels jittery, nervous, and has experienced weight loss despite an increased
appetite. Her bowel movement pattern has increased in frequency, and the consistency is soft.
PMH:
• Past Medical History: none; no major medical problems
• Childhood illnesses: Mumps, measles, Rubella
• Surgeries/Procedures: No prior surgeries
• Hospitalizations: only for childbirth
• Preventative Health: Normal American diet, active tennis player on the weekends o
Colonoscopy at 58 - normal o Annual mammograms - all negative; dense breast tissue o
Immunizations: tetanus within the last 10 years, plus Varicella
Received Flu shot, Zoster vaccine, Hep C screening
• Current Meds/OTC/Alternative: Multiple vitamins, OTC calcium, OTC Metamucil 1 year ago
Allergies: NKDA
• Infectious/Travel: None reported
• OB/GYN: G2P2002, no complications, each at term without complications Social:
• Non-smoker currently; history of occasional social smoking in college.
• Drinks alcohol socially (1-2 drinks per month); denies recreational drugs
• Sexual history: married, monogamous, no history of STIs
• Occupation: retired high school science teacher Family History:
• Father died at 89 from pneumonia. He had a hx of asthma and osteoarthritis. Mother died in a
hit-and-run car accident at age 71. Maternal grandmother died of a stroke, had a history of
being nervous and was told she had thyroid issues. Maternal grandfather died in a war with no
known medical problems. Paternal grandmother died of breast cancer. Paternal grandfather
died of prostate cancer. No siblings
, History: ROS
General: feeling fatigued, jittery; having difficulty falling asleep, staying asleep, unintentional
weight loss; denies fever, chills
Skin/Hair/Nails: positive for hair thinning; denies itchy scalp, skin changes, moles, or brittle nails
Breast: denies breast discharge, lumps, scaly nipples, pain, swelling, or redness; reports
conducting SBEs
HEENT/Neck: denies changes in vision, blurred or double vision, problems with hearing, ear pain,
sinus problems, chronic sore throats, or difficulty swallowing
Cardiovascular: denies chest pain or pressure; positive for palpitations and decreased exercise
tolerance
Respiratory: denies ShOB, wheezing, chronic cough, or sputum production
Gastrointestinal: denies nausea, vomiting, or blood in stool; reports changes in stool consistency
from chronic constipation to soft/loose stool with increased frequency
Genitourinary: Denies changes with urination, including pain, burning, blood, difficulty
starting/stopping, dribbling, incontinence, urgency, or changes in frequency
Musculoskeletal/Structural: Denies muscle or joint pain, redness, swelling, muscle cramps, joint
stiffness, joint swelling, or back/neck/shoulder/hip pain
Neurologic: Denies dizziness, fainting, vertigo, seizures, weakness, numbness, tingling, or tremors;
reports mild intermittent headaches
Psychiatric: Denies depression, lack of interest, sadness, memory loss, or mood changes
Endocrine: reports feeling hot, especially with activity; denies increased urination or thirst
Hematologic/Lymphatic: denies increased bruising, bleeding gums, epistaxis, or other sites
Allergic/Immunologic: NKDA
Physical Exam
Cognitive: A&Ox4; unintentional weight loss of 9 lbs since last visit
General:
HEENT/Neck: Head -
Eyes: no erythema, or swelling; positive for lid retraction and lid lag; no proptosis, conjunctival
discharge; sclerae anicteric; no orbital edema or redness; PERRL; EOMI
Ears: EAC without erythema or cerumen; bilateral TM translucent, non-injected, no scarring,
discharge, or purulence Nose: no polyps or discharge
Mouth: oropharynx non-injected, clear mucosa, tonsils without exudate
Neck: trachea is midline; thyroid is soft, enlarged, isthmus ropey, easily palpable, slight bilateral
asymmetry R>L, no nodules palpated; thyroid moves with swallowing, no nodules palpated CV: RRR,
no murmurs or additional heart sounds; no carotid bruit auscultated
Chest/Respiratory: CTAB
Breast: normal CBE; breasts and nipples non-tender, no masses, lumps, deformities, ulcerations, or
discharge
GI: normoactive bowel sounds; no bruit auscultated over abdominal or femoral arteries; no pain,
tenderness, masses, or pulsations on palpation; no guarding or rebound tenderness; no
hepatosplenomegaly; liver span normal and liver edge is palpable; spleen is not palpable
Genitourinary/Rectal:
Musculoskeletal/Structural: muscle bulk diminished but within normal range for a non-athletic person of
this age; Hyperreflexia: DTRs - Triceps +3, Patella +3, Achilles +3; Biceps and Brachioradialis +2
Verified Study Solutions Rated A+
Reason for Encounter: Trouble sleeping
5'5" 126 lb
A&Ox4
99F
102 pulse
BP L 130/72; R 128/72 PP normal
RR 14
SpO2 94%
Last Visit: 1 year 1 month ago. Vision normal. Occasional GERD. Chronic Constipation, uses Metamucil,
coffee, exercise; Completes SBE; Denies depression; Normal endocrine;
No meds prescribed; Multi-Vitamin, Calcium daily
History: HPI
HR is a 65yo female who presents to the office with c/o sleeping difficulties. She reports intermittent
sleep issues for a couple of months but it has gotten progressively worse over the last week or so. She
describes difficulties falling asleep and staying asleep, as well as being very fatigued throughout the day.
Simultaneously, she feels jittery, nervous, and has experienced weight loss despite an increased
appetite. Her bowel movement pattern has increased in frequency, and the consistency is soft.
PMH:
• Past Medical History: none; no major medical problems
• Childhood illnesses: Mumps, measles, Rubella
• Surgeries/Procedures: No prior surgeries
• Hospitalizations: only for childbirth
• Preventative Health: Normal American diet, active tennis player on the weekends o
Colonoscopy at 58 - normal o Annual mammograms - all negative; dense breast tissue o
Immunizations: tetanus within the last 10 years, plus Varicella
Received Flu shot, Zoster vaccine, Hep C screening
• Current Meds/OTC/Alternative: Multiple vitamins, OTC calcium, OTC Metamucil 1 year ago
Allergies: NKDA
• Infectious/Travel: None reported
• OB/GYN: G2P2002, no complications, each at term without complications Social:
• Non-smoker currently; history of occasional social smoking in college.
• Drinks alcohol socially (1-2 drinks per month); denies recreational drugs
• Sexual history: married, monogamous, no history of STIs
• Occupation: retired high school science teacher Family History:
• Father died at 89 from pneumonia. He had a hx of asthma and osteoarthritis. Mother died in a
hit-and-run car accident at age 71. Maternal grandmother died of a stroke, had a history of
being nervous and was told she had thyroid issues. Maternal grandfather died in a war with no
known medical problems. Paternal grandmother died of breast cancer. Paternal grandfather
died of prostate cancer. No siblings
, History: ROS
General: feeling fatigued, jittery; having difficulty falling asleep, staying asleep, unintentional
weight loss; denies fever, chills
Skin/Hair/Nails: positive for hair thinning; denies itchy scalp, skin changes, moles, or brittle nails
Breast: denies breast discharge, lumps, scaly nipples, pain, swelling, or redness; reports
conducting SBEs
HEENT/Neck: denies changes in vision, blurred or double vision, problems with hearing, ear pain,
sinus problems, chronic sore throats, or difficulty swallowing
Cardiovascular: denies chest pain or pressure; positive for palpitations and decreased exercise
tolerance
Respiratory: denies ShOB, wheezing, chronic cough, or sputum production
Gastrointestinal: denies nausea, vomiting, or blood in stool; reports changes in stool consistency
from chronic constipation to soft/loose stool with increased frequency
Genitourinary: Denies changes with urination, including pain, burning, blood, difficulty
starting/stopping, dribbling, incontinence, urgency, or changes in frequency
Musculoskeletal/Structural: Denies muscle or joint pain, redness, swelling, muscle cramps, joint
stiffness, joint swelling, or back/neck/shoulder/hip pain
Neurologic: Denies dizziness, fainting, vertigo, seizures, weakness, numbness, tingling, or tremors;
reports mild intermittent headaches
Psychiatric: Denies depression, lack of interest, sadness, memory loss, or mood changes
Endocrine: reports feeling hot, especially with activity; denies increased urination or thirst
Hematologic/Lymphatic: denies increased bruising, bleeding gums, epistaxis, or other sites
Allergic/Immunologic: NKDA
Physical Exam
Cognitive: A&Ox4; unintentional weight loss of 9 lbs since last visit
General:
HEENT/Neck: Head -
Eyes: no erythema, or swelling; positive for lid retraction and lid lag; no proptosis, conjunctival
discharge; sclerae anicteric; no orbital edema or redness; PERRL; EOMI
Ears: EAC without erythema or cerumen; bilateral TM translucent, non-injected, no scarring,
discharge, or purulence Nose: no polyps or discharge
Mouth: oropharynx non-injected, clear mucosa, tonsils without exudate
Neck: trachea is midline; thyroid is soft, enlarged, isthmus ropey, easily palpable, slight bilateral
asymmetry R>L, no nodules palpated; thyroid moves with swallowing, no nodules palpated CV: RRR,
no murmurs or additional heart sounds; no carotid bruit auscultated
Chest/Respiratory: CTAB
Breast: normal CBE; breasts and nipples non-tender, no masses, lumps, deformities, ulcerations, or
discharge
GI: normoactive bowel sounds; no bruit auscultated over abdominal or femoral arteries; no pain,
tenderness, masses, or pulsations on palpation; no guarding or rebound tenderness; no
hepatosplenomegaly; liver span normal and liver edge is palpable; spleen is not palpable
Genitourinary/Rectal:
Musculoskeletal/Structural: muscle bulk diminished but within normal range for a non-athletic person of
this age; Hyperreflexia: DTRs - Triceps +3, Patella +3, Achilles +3; Biceps and Brachioradialis +2
