Hospital Visit 2 H & P

History

Identifying Data:

Full Name: Mrs. D. M.

Address: Queens, NY

Date of Birth: Sep 23, 1939

Date & Time: Nov. 6, 2018 / 9:15 a.m.

Location: Internal Medicine, NYHQ, Flushing, NY

Religion: Atheists

Source of information: Self

Reliability: Reliable

Source of Referral: None

Mode of Transport: Ambulance

CC: “I can’t talk and very bad headache” X 1 hr

HPI:

Mrs. D. M. is a reliable 79 y/o married, Caucasian female, with a history of CAD, HTN and HLD who presented to the ED 1 week ago with headache and aphasia for the past 1 hour. She was last seen normal around 7 a.m. after woke up. She had a sudden onset of aphasia and forehead pain with temporary decreased level of consciousness when she cooked breakfast in the kitchen. The forehead headache was a constant aching pain with numbness of the right face. The pain radiated down to the neck and upper back on the right side. Patient describes the headache as a dull pressure pain in character and last approximately 10 minutes. The patient took Body Aspirin and the pain was alleviated gradually. The pain is not worsened by anything. Pt rates the pain as 10/10 at its worst. She was brought by EMS to the ED 1 hour later after the onset of symptom, and then transferred to the internal medicine after the aphasia was relieved. She c/o vertigo after waking up in the morning, and trouble with walking due to the weakness of the legs during the past 7 days. Pt also c/o nausea and vomiting occasionally. She denies recent illness, paralysis of the arms, diplopia, blurred, or blackened vision in one or both eyes, eyelid droopiness, head trauma, fever, tinnitus or other neurologic symptoms, SOB, or PND. Pt states she has experienced CAD with six coronary stents placement in the past. She also has experienced stumble and sudden dizziness in January this year.

Past Medical History:

Present illnesses – CAD x 9 years; HTN x 10 years; chronic back pain x 15 years.

Past medical illness – appendicitis 20 years ago.

Hospitalizations – Appendectomy on 1998 (unable to recall hospital/surgeon name and address); 6 stents placement on XXXX (pt forgot the time, and unable to recall hospital/surgeon name and address)

Childhood illnesses – denies any illnesses.

Immunization – up to date; flu vaccine yearly.

Screening test and results – denies recent screening.

Past Surgical History:

Appendectomy – 1998, due to appendicitis, no complications.

Stents placement – XXXX, due to CAD, no complications.

Denies past injuries or transfusions.

Medications:

Clopidogrel (25 mg), 1 tab p.o. daily for stroke, last dose yesterday morning.

Isosorbide (30mg), 1 tab p.o. daily for HTN, last dose yesterday morning

Pantoprazole (40mg), 1 tab p.o. B.I.D. for stomach acid, last dose yesterday morning

Atorvastin (20 mg), 1 tab p.o. daily for high cholesterol, last dose yesterday morning

Heparin subp injection for anticoagulant

Allergies:

Denies any drug, food, enviroment allergies.

Family history:

Mother – Deceased at age 70s, lung cancer

Father – Deceased at age 60s, liver disease

Sister – Deceased at age 70s, lung cancer

Sister – Deceased at age 70s, lung cancer

Daughter – 40s, alive and well

Son – 40s, alive and well

Maternal/paternal grandparents – Deceased at unknown age & unknown reasons

Social History:

Mrs. T. S. is a married female, living with her husband and 3 cats. She is retired casher.

Habits – She denies drinking alcohol/beer, smoking cigarettes/cigars, or illicit drug use. She drinks one cups of tea every day.

Travel – She denies traveling recently.

Diet – she has a small amount of diet with cupcake, yogurt, chicken, vegetable, and fruit.

Exercise – she walks about 4 blocks away once or twice per week to buy some food in her community neighborhood. She sleeps well and average 6 hours per day.

Safety measures – admit to wearing a seat belt.

Review of systems:

General – states she has loss of appetite recent 1 month, and fatigue for 1 week. Denies recent weight loss or gain, generalized, 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 – states she has forehead pain for 1 hours one week ago, vertigo for past 7 days. Denies head trauma, unconsciousness, coma, or fracture.

Eyes – denies visual disturbance (blurring, diplopia, fatigue with use of eyes, scotoma, halos), lacrimation, photophobia, pruritus. Denies recent eye exam, or use of glasses.

Ears – denies deafness, pain, discharge, tinnitus or use of hearing aids.

Nose/sinuses – denies discharge, epistaxis, or obstruction.

Mouth and throat – denies bleeding gums, sore tongue, sore throat, mouth ulcers, voice changes or use dentures. Denies recent dental exam.

Neck – states she has stiffness of the right side neck. Denies localized swelling/lumps.

Breast – denies lumps, nipple discharge, or pain. Last mammogram 2018, negative.

Pulmonary system – denies dyspnea, dyspnea on exertion, cough, wheezing, hemoptysis, cyanosis, orthopnea, or paroxysmal nocturnal dysnea.

Cardiovascular system – Has a history of CAD x 9 years with 6 stents placement; HTN x 10 years. Denies edema/swelling of ankles or feet, syncope, or known heart murmur.

Gastrointestinal system – states she has nausea and vomiting occasionally and loss appetites for past 7 days. Has regular bowel movements daily. Denies intolerance to specific foods, dysphagia, pyrosis, unusual flatulence or eructations, abdominal pain, diarrhea, jaundice, hemorrhoids, constipation, rectal bleeding, or blood in stool.

Genitourinary system – states she has urinary frequency and polyuria. Denies nocturia, oliguria, dysura, incontinence, awakening at night to urinate or flank pain.

Sexual Hx – states she is currently sexually inactive. Denies STI or contraception.

Menstrual and obstetrical – menarche age 10, menopause age 60. Denies hot flashes or associated menopausal symptoms. G4T4P0A0L2, no complications.

Nervous system – states she has forehead headache with temporary decreased level of consciousness. Denies seizures, loss of consciousness, sensory disturbances, ataxia, loss of strength, or change in cognition/mental status/memory.

Musculoskeletal system – states she has chronic back pain. Denies 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.

Hematologic system – denies anemia, easy bruising or bleeding , lymph node enlargement, blood transfusions, or history of DVT/PE

Endocrine system – states she has polyuria. Denies polydipsia, polyphagia, heat or cold intolerance, excessive sweating, hirsutism, or goiter.

Psychiatric – states she has temporary depression. Denies anxiety, OCD or ever seeing a mental health professional.

Physical

 

Vital Signs:

BP: L 128/78, supine

RR: 16/min unlabored

P: 68, regular

T: 98.5 degree F (oral)

O2 Sat: 100% room air

Ht: 61 inches

Wt: 125 lbs.

BMI: 23.6

 

General: Patient is a 79 y/o female, alert and oriented times 3. Well developed and good posture. Well dressed, groomed and nourished. No apparent distress.

Skin/Nail/Head/Hair:

Skin – warm & moist, good turgor. No increase or loss in pigmentation, nonicteric, no thick, opaque, no scar, tattoos, no rashes or suspicious lesion

Hair – average quantity and soft of hair, evenly distribution, no signs of lice, nits, no seborrhea. Nails: no clubbing, capillary refill < 2 seconds throughout.

Head – eyes and ears aligned, normocephalic, atraumatic, non tender to palpation throughout, no trauma, no specific facies.

Eye: symmetrical OU, no evidence of strabismus, exophthalmos or ptosis. Sclera white, conjunctiva and cornea clear. Visual acuity (uncorrected – 20/20 OS, 20/20 OD, 20/20 OU). Visual fields full OU. PERRLA , EOMs full with no nystagmus. Fundoscopy -Red reflex intact OU.   Cup:Disk < 0.5 OU, no evidence of A-V nicking, papilledema, hemorrhage, exudate, cotton wool spots, or neovascularization OU.

Ears: Symmetrical and normal size.  No evidence of lesions, masses, trauma on external ears.  No discharge, foreign bodies in external auditory canals AU. TM’s pearly white, intact with light reflex in normal position AU. Auditory acuity intact to whispered voice AU.  Weber midline, Rinne reveals AC>BC AU.

Nose/Sinues:

Nose – Symmetrical, no obvious masses, lesions, deformities, trauma, discharge. Nares patent bilaterally. Nasal mucosa pink and well hydrated. No discharge noted on anterior rhinoscopy.  Septum midline without lesions, deformities, injection, perforation. No evidence of foreign bodies.

Sinuses – Non tender to palpation and percussion over bilateral frontal, ethmoid and maxillary sinuses.

Mouth/Throat:

Lips -Pink, moist. no evidence of cyanosis or lesions. Non-tender to palpation.

Mucosa – Pink and well hydrated. No masses, lesions noted. No evidence of leukoplakia. Non-tender to palpation.

Palate – Pink and well hydrated. No lesions, masses, scars. Non-tender to palpation.

Teeth – Good dentition. No obvious dental caries noted. Non-tender to palpation.

Gingivae – Pink and moist. No evidence of hyperplasia, masses, lesions, erythema or discharge. Non-tender to palpation.

Tongue – Pink and well papillated. No masses, lesions or deviation noted. Non-tender to palpation.

Oropharynx – Well hydrated. No evidence of injection, exudates, masses, lesions, foreign bodies. Tonsils present with no evidence of injection or exudate. Uvula pink, no edema, lesions

Neck/Thyroid:

Neck – Trachea midline. No masses, lesions, scars, pulsations noted. Supple, non-tender to

palpation. No stridor noted, no thrills. Bruits noted bilaterally, no palpable adenopathy noted.

Thyroid – Non-tender to palpation, no masses, no thyromegaly, no bruits noted.

Thorax and Lungs:

Chest – Symmetrical, no deformities, no evidence trauma. Respirations unlabored, no paradoxic respirations or use of accessory muscles noted. Lat to AP diameter 2:1. Non-tender to palpation.

Lungs – Clear to auscultation and percussion bilaterally. Chest expansion and diaphragmatic excursion symmetrical. Tactile fremitus intact throughout. No adventitious sounds.