Physical Diagnosis HPI 1

HPI 1:

Hospital Visit HPI: PAT

Identifying Data:

Full Name: Mrs. MR

Sex: Female

Date of Birth: 01/29/1954

Location: NYS Presbyterian Flushing, Queens

Date and Time: March 15th, 2022- 8:10 A.M

Race: Hispanic

Religion: Catholic

Source of Information: Self

Reliability: Reliable

Referral Source: Self

Chief Complaint:

 “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

Surgical History:

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

Medications

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

Allergies:

Denies Drug Allergies

Denies Food Allergies

Denies seasonal allergies

Denies pet allergies

Denies environmental allergies

Family History:

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

Social History

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

ROS:

General:

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 

Head 

Denies headache, vertigo, head trauma, coma, fracture, and unconsciousness

Eyes 

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

Ears 

Denies deafness, pain, discharge, tinnitus, hearing aids

Nose/Sinuses 

Denies discharge, epistaxis, obstruction

Mouth and throat 

Admits to dental exam 10/2021 – Unremarkable results. Denies bleeding gums, sore tongue, sore throat, mouth ulcers

Neck 

Admits to stiffness and decreased range of motion in neck. Denies localized swelling/lumps.

Breast

Denies lumps, nipple discharge, or pain. Last mammogram 06/20/2020

Pulmonary System 

Denies Dyspnea (SOB) / dyspnea on exertion (DOE), cough, wheezing, hemoptysis, cyanosis

Cardiovascular System 

Admits to Edema/Swelling of ankles or feet. Denies HTN, palpitations, chest pain, and known heart murmur

Gastrointestinal System 

Admits to loss of appetite. Denies intolerance to specific foods, flatulence, diarrhea, jaundice, constipation, rectal bleeding, N/V

Genitourinary System 

Admits to polyuria. Color of urine yellowish. Denies flank pain, oliguria, nocturia, dysuria

Sexual History

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

Nervous System 

Denies dizziness, near-syncope, seizures, headaches, sensory disturbances, loss of strength, weakness, and change in cognition.

Musculoskeletal System 

Admits to muscle/joint pain, swelling, redness, and arthritis.

Peripheral Vascular System 

Denies intermittent claudication, coldness or trophic changes, or color change

Hematologic System 

Denies anemia, easy bruising or bleeding, lymph node enlargement or Blood transfusions

Endocrine System 

Admits to polyuria. Denies polydipsia / polyphagia, heat or cold tolerance, excessive sweating, goiter

Psychiatric 

Admits to depression/sadness. Admits to seeing a psychiatrist weekly – No medications. Denies anxiety, OCD.

Physical

Vitals:

Height: 5’2

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