New Patient History and Physical

Patient Name: Happy Hour...Somewhere
#1234

Date: April 9, 2010

Chief Complaint: Ennui. 

History of Present Illness: The patient is a slightly overweight 52-year-old female who appears somewhat jittery and tends to perseverate on what is wrong. Tended to go off on wild tangents and ramble. She said she has been bored for the last several months. When pressed on the issue, she claims she has to be bored because she is starting to know more reality TV people than real people. RuPaul's Drag Race is the bomb. The Real Housewives of New York drive her crazy but she cannot stop watching. Will Jill pull her head out of her arse? Will Bethenny ever shut up? Will LuAnn shed her skin? Will Ramona finally have her head spin off? Will Alex realize Simon is gay? (I will have to investigate this further.) At this point, I had to bring the patient back to reality (ha, ha) and continue with the evaluation. 

Past medical history: Usual childhood illnesses. History of breaking a windshield with her head, which may explain a lot. 

Past surgical history: Something about tubes and baby factory closed down...probable tubal ligation. 

Medications: None but badly in need of something. 

Allergies: No known drug allergies but totally seems allergic to keeping her story straight. 

Social history: No smoking history but I smelled cigarettes on her. She said she just snuck a puff from her friend's son. Claim to drink alcohol rarely but wears a Jack Daniels t-shirt. I would say she is a moderate drinker. 

Review of systems: Patient checked off no to everything....whatever. 

Physical Examination: 
General: A slightly overweight, somewhat anxious, 52-year-old female who appears her stated age. (The patient was a little huffy with this assessment.)

Vital signs: Weight: Patient refused to get on scale and got quite belligerent with the staff. Claims we always lie and step on the scale when she is not looking so she weighs more. (Possible paranoia?) Height: Short. Blood pressure: Through the roof. Pulse: Whoa boy! 

HEENT:
Head: Small, slightly pointy. Old bump on forehead. 
Eyes: Check thyroid as eyes are slightly buggy. Pupils dilated. (Perform random urine drug screen.)
Ears: Possible hearing loss as her kids claim she never listens. 
Nose: Pollybeak deformity.
Throat: Turkey wattle deformity. 

Skin: Pasty. Vampire like. 

Genitourinary: She said the next man that got a gander at her happy place better not be slapping a speculum there. 

Rectal: The patient said "as if." 

Musculoskeletal: Moved all 4 extremities well but a little spastic. Reflexes slightly hyperreflexic. 

Neurologic: Cranial nerves II-XII are intact except for hearing. Failed memory test. Had no idea of the date. Wanted to know if it was 2012 yet and something about the end of the world. 

Radiographic studies: MRI of the head showed nothing. Ditto a CT scan. 

Diagnosis:   Ennui.

Assessment and plan: 
1.   Boring people are bored. 
2.   Get out. Do Happy Hour at least once a week. 
3.   Sit at the coffee shop with your friends once a week. 
4.   Get outside. Told the patient she would not sparkle or turn into dust.
5.   Take the dang dog for a walk. 


Signed by Dr. Know It All

See, this is why I never go to the doctor. They write fiction.