Present Illness of Diplopia - Case Study Example

No significant family history in parents. Both parents alive, active and healthy.Personal and social historyMarried for 28 years. Has 6 children between 10- 25 years ago. Works as Sales Clerk Manager at a departmental store enjoys knitting and sewing, acts as Girl Scout Troop Leader and leads an educational course at her Catholic church. Exercise and diet: Exercises 2-3 times a week and gets most exercise by chasing her children. Takes diet appropriate for hypercholesterolemia. Takes a multivitamin once a day.

Safety measures: Ask about the use of seat belts, sunblock, etc.Ask h/o eyeglasses, hearing problems, vertigo, tinnitus, sinusitis, recurrent nasal allergy, hay fever?Neck: Any pain, goiter, lumps, swollen glands?Breasts: H/O of cyst removal four years ago. Ask h/o recurrence of cysts, lumps, pain, nipple discharge. Ask if examines breast regularly one-selfCardiovascular: Ask h/o blood pressure, chest pain, palpitations, chest tightness, dyspnoea, orthopnea. Ask h/o ECG takenGastrointestinal: Ask h/o of appropriate appetite, nausea, vomiting, indigestion, the regularity of bowel movements.

Ask h/o change in bowel movements, constipation, diarrheaUrinary: Ask h/o dysuria, hematuria, recent flank pain, nocturia, dribbling of urine while coughingGenital: Ask h/o vaginal or pelvic infections. Ask h/o dyspareuniaMusculoskeletal: Ask h/o back pain or pain elsewherePsychiatric: Ask h/o depressionNeurologic: Ask h/o seizures, fainting, motor or sensory loss.Physical ExaminationDescribe her appearance, temperament, dress sense, color and comfort level.Vital signsNo fever, pulse rate 69 per minute, respiratory rate 28 per minute, blood pressure- 136/78 per minute.

SkinLook for pallor, icterus, cyanosis, lymph node, edema, rash, koilonychiaHEENTExamine the eyes with torchlight, the retina with an ophthalmoscope, the ears with otoscope and nostrils and throat with torchlight. Look for symmetry of pupil, reaction to light and color of the conjunctiva. Look at the tympanic membrane. Look for congestion of the throat, tonsillar enlargement, flaring of nostrils and postnasal drip.