Full H & P 3 – FM

Identifying Data:

Full Name: Mr. T

DOB (Age):  61

Gender: Female

Date & Time: July. 8, 2020 / 2:00 PM

Location: SSS-FM, Far Rockway, NY

Source of information: Self

Reliability: Reliable

Chief Complain: Left foot pain x 1 day (hospital discharge follow up)

HPI:

61-year-old male POD # 10 after a surgical repair to his left foot on 6/27 after stepping on glass where a yellow pustule was discharged on 07/01. He was seen at Mt. Sinai South Nassau where surgery was performed on his foot, and is currently taking antibiotics (Augmentin) that were prescribed to him. Patient is presenting for medication refills today as well as an extension of pain medication (oxycodone 5 mg q8h; last dose 12 pm yesterday) for the pain, which rated 9/10 in his left foot. Patient has not taken any other medication. Patient had fever and chills initially but denies at present. Patient states when he looked at his bandaged foot today, he saw blood through his bandage. Patient denies any other acute complaints.

Past Medical History:

• Present illnesses –HTN & HLD x 20 years; T2DM x 10 years
• Past medical illness – none
• Childhood illnesses – None
• Immunization – Up to date; last flu vaccine yearly.
• Screening tests and results – prostate cancer screening (PSA): within normal range last year.

Past Surgical History:

Foot repair surgery 06/2020

Home Medications:

• Glyburide-Metformin Tablet, 5-500 mg, 1 tablet with a meal, orally, twice a day
• Gabapentin Tablet, 800 mg, 1 tablet, orally, three times a day
• Losartan Potassium Tablet, 50 mg, 1 tablet, orally, once a day

Allergies:

• Pt has no known allergies

Family history:

• Brother – 50s, alive with HTN
• Sister – 60s. alive with HTN, T2DM
• Son – 40s, alive and healthy
• Son– 30s, alive and healthy

Social History:

Married, living with his wife in an apartment. Drinking alcohol socially, former smoker, or illicit drug use. Denies recent traveling history. Regular diet. Routine running. Denies sleeping problem. Sexually active with his wife.

Review of systems:

General –No appreciable disease.  Patient denies generalized weakness recent weight loss or weight gain, loss of appetite, or night sweats

Skin, hair, nails – Denies changes in texture, excessive dryness or sweating, discolorations, pigmentations, or changes in hair distribution.

Head – Denies headaches, vertigo, head trauma, unconsciousness, coma, or fracture.

Eyes –Denies diplopia, fatigue with use of eyes, scotoma, halos, lacrimation, photophobia, pruritus. Last eye exam: none.

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. Last dental exam: none.

Neck – Denies localized swelling/lumps or stiffness/decreased range of motion.

Breast – Denies lumps, nipple discharge, or pain.

Pulmonary system – Denies wheezing, dyspnea, cough, hemoptysis, cyanosis, orthopnea, or paroxysmal nocturnal dyspnea (PND).

Cardiovascular system – States h/o HTN, HLD, currently stable by meds. Denies chest pain, palpitation, irregular heartbeat, edema/swelling of ankles or feet, syncope or known heart murmur.

Gastrointestinal system –Regular bowel movements daily. Denies nausea, loss appetites, intolerance to specific foods, dysphagia, pyrosis, unusual flatulence or eructations, diarrhea, jaundice, hemorrhoids, constipation, rectal bleeding, or blood in stool.

Genitourinary system – Denies urinary frequency, polyuria, nocturia, oliguria, dysuria, incontinence, awakening at night to urinate or flank pain.

-Sexual History: States he is currently sexually active. Denies STI or contraception.

Nervous system – Denies seizure, loss of consciousness, sensory disturbances, ataxia, or change in cognition/mental status/memory.

Musculoskeletal system –Denies muscle pain, or deformity.  

• Positive: Left heel pain and bleeding

Peripheral vascular system – denies intermittent claudication, coldness or trophic changes, varicose veins.

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

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

Psychiatric – Denies depression, sadness, anxiety, obsessive, or any experience of seeing a mental health professional.

Differential Diagnosis:

• Wound dehiscence
• Surgical wound infection
• Unspecified open wound, Postoperative hemorrhage

Physical Examination:

Vital Signs:

 

• BP 130/70, sitting position, left arm
• HR 104 bpm, tachycardia
• RR 18 breaths per minute, regular
• O2 98%, room air
• T 98.5 oral
• Ht 67 in Wt 192 lbs     BMI 30.04

General: Patient is a 61-year-old male, A&O x 3. Well-developed and good posture. Well dressed, groomed, and nourished. No apparent distress.

• Positive: in mild distress

Skin: warm & dry, good turgor. No scar, increase or loss in pigmentation, nonicteric

• Positive: left heel wrapped in gauze

Nail: no clubbing. Capillary refill < 2 seconds throughout. Nails are trim

Hair: average quantity and soft of hair, evenly distribution, no signs of lice, nits, no seborrhea.

Head: eyes and ears aligned, normocephalic, atraumatic, non-tender to palpation throughout, except left frontal area. no trauma, no specific facies.

Eye: Symmetrical OU; no redness, no strabismus, exophthalmos or ptosis; sclera white; conjunctiva & cornea clear. Visual fields full OU. PERRL, EOMs full with no nystagmus.

Ears: Symmetrical, no evidence of mass, lesion, erythema, inflammation, ear canal atresia. Non tender to palpation. Auditory Acuity: whisper test, intact to whispered voice AU.

Nose/Sinuses:

Nose – Symmetrical, no evidence of mass, lesion, deformities, erythema, inflammation. Non-tender to palpation and no step-off. no evidence of nasal obstruction

Sinuses – Non tender to palpation

Mouth/Throat:

Pink and well hydrated lip, gingivae, tongue, mucosa, and palate. No masses, lesions, erythema, exudate or discharge noted. Good dentition. No obvious dental caries noted. Non-tender to palpation. Uvula pink, no edema, deviation.

Neck/Thyroid:

Trachea midline. 2+ Carotid pulses. No masses, lesions, scars, pulsations noted. No stridor, thrills, bruits noted bilaterally. No palpable adenopathy noted. Non-tender to palpation, no thyromegaly 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. No adventitious sounds. No stridor, respiratory distress.

 

Cardiovascular:

Regular rate and rhythm (RRR); S1, S2 noted; No gallops, S3 or S4. No JVD. Carotid pulse 2+ bilaterally without bruits.

Abdomen:

Obese, symmetrical, no evidence of scars, striae, caput medusae or abnormal pulsations. BS present in all 4 quadrants. No bruits noted over aortic/renal/iliac/femoral arteries. Tympany to percussion throughout. No evidence of organomegaly. No masses noted. No evidence of guarding or rebound tenderness. No CVAT noted bilaterally.

Male Genitalia/Rectal: Patient refused the exams.

Peripheral Vascular System: Skin normal in color and warm to touch upper and lower extremities bilaterally.  No calf tenderness bilaterally. No palpable cords or varicose veins bilaterally.

Neurological:

Mental Status: Alert and oriented to person, place and time. Memory and attention intact. Receptive and expressive abilities intact. Thought coherent. No dysarthria, dysphonia or aphasia noted.

Cranial Nerves

• I – Intact no anosmia.
• II- Visual fields by confrontation full.
• III-IV-VI- PERRL, EOM intact without nystagmus.
• V- Facial sensation intact, strength good.
• VII- Facial movements symmetrical and without weakness.
• VIII- Hearing grossly intact to whispered voice bilaterally.
• IX-X-XII- Swallowing and gag reflex intact. Uvula elevates midline. Tongue movement intact.
• XI- Shoulder shrug intact.

Motor/Cerebellar: Full active/passive ROM of B/L upper and lower extremities without rigidity or spasticity. Normal muscle bulk and tone. No atrophy, tics, tremors or fasciculations. Strength equal and appropriate for age bilaterally (5/5 throughout). Coordination-finger to nose intact. Normal gait.

Sensory: For b/l upper and lower extremity, Intact to light touch, sharp/dull, point localization, extinction.

Reflexes

• Patellar : R-2+ ; L-2+

Meningeal Signs: No nuchal rigidity noted. Brudzinski’s and Kernig’s signs are negative.

Musculoskeletal: No erythema / ecchymosis / atrophy / or deformities in bilateral upper and lower extremities. No crepitus noted throughout. No evidence of spinal deformities. FROM of all upper and lower extremities.  No evidence of spinal deformities.

• Positive: Blood expressed from left heel, wound wrapped in gauze.

Assessment and Plan:

61-year-old male POD # 10 after a surgical repair to his left foot presents with left foot pain for 1 day. History and epigastric tenderness most consistent with wound dehiscence.

1. Wound dehiscence:
   • Follow up appointment at St John’s hospital tomorrow for wound care
   • RTO or ER if pain/bleeding worsen
2. T2DM:
   • Refill Glyburide-Metformin Tablet, 5-500 mg, 1 tablet with a meal, orally, twice a day
   • Refill Gabapentin Tablet, 800 mg, 1 tablet, orally, three times a day
   • Low sugar/carb diet and exercise
3. Essential hypertension:
   • Refill Losartan Potassium Tablet, 50 mg, 1 tablet, orally, once a day
   • Low salt diet and exercise