Hospital Visit HPI: PAT
Full Name: Mrs. MR
Date of Birth: 01/29/1954
Location: NYS Presbyterian Flushing, Queens
Date and Time: March 15th, 2022- 8:10 A.M
Source of Information: Self
Referral Source: Self
“I am here for my pre-assessment for my surgery tomorrow”
History of Present Illness:
68-Year-old Female Patient with a PMH of Arthritis, L Knee replacement, and Right knee pain X 5 years presents for preadmission testing for Right knee replacement. Patient states that she has not been able to walk without continuous joint pain for the last 5-10 years. Patient reports swelling and erythema in her Right knee. Patient states that the pain is a 10/10 while walking, sitting, and standing and that she feels the pain radiating to her lower back. Patient has taken 500mg Tylenol with mild relief for her arthritis and knee pain. Patient denies trauma, fever, sweats, and night chills.
Past Medical history:
Rheumatic fever 50 years ago, resolved
Pre-Diabetes x 5 years
Arthritis x 10 years
Hyperlipidemia X 10 Years, well controlled on medications
GERD x 10 Years, well controlled on medications
Depression X 3 years
Immunizations: Up to date; COVID Vaccine + Booster; No Annual Flu shot
Left Knee Replacement 1 year ago: 6/1/2021 at NYS Presbyterian, Flushing, NY uncomplicated
C-Section 30 Years ago: 5/02/1992 uncomplicated
Total salpingectomy for Ectopic Pregnancy 29 years ago: 4/13/1993 uncomplicated
Denies history of eye surgery, hernia surgery, or history of transfusions
Omeprazole 40mg, 1 tab PO BID for GERD, Last Dose this morning
Atorvastatin unknown mg, 1 tab PO daily for Cholesterol, Last dose last night
Denies Drug Allergies
Denies Food Allergies
Denies seasonal allergies
Denies pet allergies
Denies environmental allergies
Mother: Deceased at 72 years old due to Breast cancer. Admits History of Breast Cancer, Colon cancer, diabetes, arthritis.
Father: Deceased. Unknown medical history. Passed away before patient was born at 27 years old due to MVA
Maternal and Paternal Grandparents deceased. Medical history unknown
Daughter: 30 years old, Alive and well
Alcohol: Denies past and current alcohol use
Smoking: Denies past and current Smoking
Drug use: Denies past and current marijuana, cocaine and recreational drug use
Marital Status: Widow that is Single and lives alone
Caffeine: Drinks 1 cup of Coffee Daily
Travel: Recent Travel to Columbia 1/26/2022 for duration of 1 month
Diet: Drinks 1 cup of Coffee daily and abides by fat free vegetarian diet
Occupational History: Retired babysitter
Exercise: Patient does not exercise and sleeps well 8 hours daily
Admits to loss of appetite and recent weight loss. Denies recent weight gain, generalized weakness/fatigue, fever or chills, and night sweats.
Skin, hair and nails
Admits to excessive dryness, discoloration, moles/rashes. Denies changes in texture, pigmentations, pruritus, and changes in hair distribution
Denies headache, vertigo, head trauma, coma, fracture, and unconsciousness
Admits to wearing reading glasses and last eye exam 8 months ago 09/2021- does not know her visual acuity; normal pressure. Denies visual disturbance – blurring, diplopia, fatigue with use of eyes, scotoma, halos, photophobia, lacrimation
Denies deafness, pain, discharge, tinnitus, hearing aids
Denies discharge, epistaxis, obstruction
Mouth and throat
Admits to dental exam 10/2021 – Unremarkable results. Denies bleeding gums, sore tongue, sore throat, mouth ulcers
Admits to stiffness and decreased range of motion in neck. Denies localized swelling/lumps.
Denies lumps, nipple discharge, or pain. Last mammogram 06/20/2020
Denies Dyspnea (SOB) / dyspnea on exertion (DOE), cough, wheezing, hemoptysis, cyanosis
Admits to Edema/Swelling of ankles or feet. Denies HTN, palpitations, chest pain, and known heart murmur
Admits to loss of appetite. Denies intolerance to specific foods, flatulence, diarrhea, jaundice, constipation, rectal bleeding, N/V
Admits to polyuria. Color of urine yellowish. Denies flank pain, oliguria, nocturia, dysuria
No longer sexually active. Denies STIs, and contraceptives.
Menstrual and Obstetrical: Admits to post menopause X 20 years. Date of LMP unknown. Denies breakthrough bleeding/spotting or vaginal discharge
Denies dizziness, near-syncope, seizures, headaches, sensory disturbances, loss of strength, weakness, and change in cognition.
Admits to muscle/joint pain, swelling, redness, and arthritis.
Peripheral Vascular System
Denies intermittent claudication, coldness or trophic changes, or color change
Denies anemia, easy bruising or bleeding, lymph node enlargement or Blood transfusions
Admits to polyuria. Denies polydipsia / polyphagia, heat or cold tolerance, excessive sweating, goiter
Admits to depression/sadness. Admits to seeing a psychiatrist weekly – No medications. Denies anxiety, OCD.
Weight: 157 lbs.
BP: Left Arm: 124/81; Right Arm: 125/80
Pulse: 84, Regular
O2 Saturation: 98%
Temp: 97.8 F (Oral)
RR: 15/Min unlabored
***Ran out of time at this point as patient had to get EKG performed and Blood drawn**
General: Patient is a well appearing female, neatly groomed, in no acute distress.
Skin: warm & moist, good turgor. Nonicteric, no lesions noted, no scars, tattoos.
Hair: average quantity and distribution.
Nails: no clubbing, capillary refill <2 seconds throughout
Head: Normocephalic, atraumatic, non-tender to palpation throughout
Eyes – symmetrical OU / no evidence of strabismus, exophthalmos or ptosis / sclera white /conjunctiva & 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 / neovascularization O