History and Physical
All identifying patient information was changed to protect patient privacy.
History
Identifying Data:
Name: Doe, Jane
Race: Latina
Date of Birth: 1/1/1956
Address: Queens, NY
Location: New York Queens Hospital, Flushing, NY
Religion: unknown
Source of Information: Self
Reliability: not reliable
Source of referral: self
Chief Complaint:
“I have pain in my abdomen” x 2 hours
History of Present Illness:
Mrs. Doe is an unreliable 63 year old married, Brazilian female, with a past medical history of gallstones, who presents to Preadmission Testing with a complaint of constant sharp right upper quadrant abdominal pain. The pain started 2 hours ago after eating meat. The pain radiates to her back. She states the pain is 7/10. She states the pain is worsened after eating meat, corn, and milk products. She states she can’t do anything to alleviate the pain. She has experienced these attacks numerous times before. She has experienced nausea and vomiting on occasion. She denies changes in appetite, dysphagia, pyrosis, flatulence, eructation, diarrhea, jaundice, changes in bowel habits, constipation. Patient has experienced gallstone attacks multiple times, and was recommended to have a cholecystectomy.
Note: The patient was a poor historian and I was unable to pinpoint the onset.
Past Medical History:
Present Illnesses:
Hypertension for 10 years
Gallstones for 2 years
Kidney stones for 2 years
Childhood Illnesses:
none
Past Surgical History:
Caesarean Section 1994 no complications, 1996 no complications
Breast Augmentation 1998 no complications
Hysterectomy 2011 no complications
Removal of breast implant 2017 no complications
No blood transfusions
Immunizations:
Patient has all childhood vaccines
Zostavax, February 2019
Influenza, October 2019
Medications:
Metoprolol Succinate extended release 50 mg 1 pill by mouth QD
Potassium Citrate extended release 10 mEq 2 pills by mouth TID
Allergies:
No allergies to food, environment and drugs
Family History:
Mother: Diabetes, Hypertension, died of an aneurysm 75 years old
Father: patient doesn’t know she said he had a pulmonary problem, deceased unknown cause 85 years old
Sister: kidney stones, 65 years old alive and well
Brother: 61 years old alive and well
Brother: kidney stones, 60 years old alive and well
Maternal Grandmother: unknown
Maternal Grandfather: unknown
Paternal Grandmother: unknown
Paternal Grandfather: unknown
Social History:
Alcohol: none
Smoking: never smoked
Illicit drug: none
Travel: no recent travels
Occupational History: retired bar tender
Diet: low sodium diet
Sleep: 4 hours a night
Exercise: Yoga or walking every day for 40 minutes
Safety: uses seatbelt
Caffeine: none
Home situation: lives at home with her husband in a safe environment
Marital status: married
Sexual history: heterosexual, monogamous. Does not use barrier protection. Denies history of sexually transmitted diseases.
Review of Systems:
General: Denies recent weight loss or gain, loss of appetite, generalized weakness/fatigue, fever or chills, or night sweats.
Skin, hair, nails: Denies changes in texture, excessive dryness or sweating, discolorations, pigmentations, moles/rashes, pruritus or changes in hair distribution.
Head: Denies headaches, vertigo or head trauma.
Eyes: Denies blurry vision, diplopia, fatigue with use of eyes, scotoma, halos, lacrimation, photophobia, pruritus. Uses reading glasses.
Ears: Denies deafness, pain, discharge, tinnitus or use of hearing aids.
Nose/sinuses: Denies discharge, epistaxis or obstruction.
Mouth/throat: Denies bleeding gums, sore tongue, sore throat, mouth ulcers, voice changes or use of dentures.
Neck: Denies localized swelling/lumps or stiffness/decreased range of motion
Breast: Denies lumps, nipple discharge, or pain.
Pulmonary system: Denies dyspnea, dyspnea on exertion, cough, wheezing, hemoptysis, cyanosis, orthopnea, or paroxysmal nocturnal dyspnea.
Cardiovascular system: Patient has hypertension. Denies chest pain, palpitations, irregular heartbeat, edema/swelling of ankles or feet, syncope, heart murmur.
Gastrointestinal system: Patient denies constipation, rectal bleeding, blood in stool.
Genitourinary system: Denies urinary frequency or urgency, nocturia, oliguria, polyuria, dysuria, incontinence, awakening at night to urinate or flank pain.
Menstrual/Obstetrical – G3P2, Caesarian section x 2, no complications. Menarche age 12. Last Menstrual Period at age 55. Currently in menopause – denies hot flashes or associated menopausal symptoms. Denies breakthrough bleeding/spotting or vaginal discharge.
Nervous: Denies seizures, headache, loss of consciousness, sensory disturbances, ataxia, loss of strength, change in cognition / mental status / memory, or weakness.
Musculoskeletal system: Denies muscle/joint pain, deformity or swelling, redness or arthritis.
Peripheral vascular system: Denies intermittent claudication, coldness or trophic changes, varicose veins, peripheral edema or color changes.
Hematological system: Denies anemia, easy bruising or bleeding, lymph node enlargement, blood transfusions, or history of deep vein thrombosis/pulmonary embolism.
Endocrine system: Denies polyuria, polydipsia, polyphagia, heat or cold intolerance, excessive sweating, hirsutism, or goiter.
Psychiatric: Denies depression/sadness, anxiety, OCD or ever seeing a mental health professional.
Exam
General: Medium build female, neatly groomed, good hygiene, good gait, good posture, looks her stated age of 19, alert, awake and oriented x3.
Vital Signs:
Blood Pressure:
Right arm:
Seated 120/70
Supine 120/70
Left arm:
Seated 120/70
Supine 120/70
Respiration: 12 breaths /min unlabored
Pulse: 64 beats per minute, regular
Temperature: 98.3 degrees F (oral)
O2 Saturation: 96% room air
Height: 65 inches
Weight: 125 lbs
BMI: 21
Skin: Warm and moist, good turgor. No discoloration, lesions, scars, or tattoos noted.
Hair: Average quantity and distribution. No lice
Nails: Capillary refill < 2 seconds throughout. No Koilonychia, paronychia, clubbing, or pitting.
Head: Normocephalic, atraumatic, non-tender to palpation, no masses or lesions throughout.
Eyes: Symmetrical OU. No strabismus, exophthalmos or ptosis. Eyebrows nicely distributed, no lacrimation, sclera white, cornea clear, conjunctiva clear. No signs of inflammation or trauma. Pupils equal, round, reactive to light. Visual acuity uncorrected – 20/20 OD, 20/20 OS, 20/20 OU. Visual fields full OU. Extraocular movement intact with no nystagmus. Red reflex intact OU. Cup to disk ratio < 0.5 OU. No AV nicking, hemorrhages, exudates or neovascularization OU.
Ears: Symmetrical, good position and size. No masses, lesions or trauma on external ears. No discharge, foreign bodies, discoloration, masses or lesions in external auditory canals AU. Tympanic membrane appears pearly white, intact with light reflex 4 o’clock AD, and 8 o’clock AS. Auditory acuity intact to whisper test AU. Weber midline, Rinne air conduction > bone conduction AU.
Nose: Symmetrical, atraumatic. No masses, lesions, deformities or discharge noted. Nares patent bilaterally. Nasal mucosa pink and well hydrated. No discharge noted on rhinoscopy exam. Septum midline without lesions, masses, deformities. No foreign bodies.
Sinuses: Not tender to palpation. Transillumination reveals maxillary and ethmoid sinuses clear bilaterally.
Mouth:
Lips: Pink and moist, no discoloration.
Mucosa: Pink, well hydrated. No masses, lesions, or scars.
Palate: Pink, well hydrated. No lesions, masses or scars noted.
Teeth: Intact with no apparent dental caries.
Gingivae: Pink. No masses, lesions or enlargement noted.
Oropharynx: Well hydrated. No injection, exudate, masses, lesions, foreign bodies. Tonsils present with no injection or exudate. Uvula pink, without lesions and non-deviated.
Neck: Trachea midline. No masses, lesions, or scars. Pulsations noted.
Thyroid: Non-tender, no palpable masses, no thyromegaly.
