History
Identifying Data:
Full name: Ms. KM
Address: Queens, NY
Date of Birth: 05/25/1973
Date and Time: 11/29/2019, 10:00 am
Location: Queens
Religion: Buddhist
Source of information: self
Reliability: Reliable
Source of referral: self
Primary physician: Dr. LJ
Chief complaint: “I have pain in my foot” x 4 months
History of Present Illness:
46 y/o single, Asian female with past medical history of hypertension, and asthma presents to the hospital with complaints of pain in her left foot, for 4 months. She states the pain started as a 4/10 and has now moved to a 10/10. She describes the pain as throbbing and states it does not radiate anywhere. The pain is aggravated by walking and is usually worse early morning as soon as she gets up and at night. The pain is present throughout the day but she it doesn’t bother her as much. The pain is not alleviated by anything. Patient has not taken any medication for the pain. Patient states joint pain – in both knees and fingers. Patient denies any recent trauma, peripheral edema.
Past Medical History
Present medical illness:
- Hypertension: 2 years
- Asthma: 7 years
Childhood illnesses: Denies any childhood illnesses
Immunization: Flu vaccination not administered this year, others up to date.
PAST SURGICAL HISTORY:
Denies past surgical history
Denies any transfusions.
Medication:
Amlodipine 10 mg- PO daily for Hypertension- did not take her medication this morning.
Loratadine 10mg – Once a day PO as needed for allergies – last dose 2 months ago.
Denies herbal supplements or vitamin use.
Allergies:
Dust – itchy nose and dry throat
Dog- sneezing
No known Drug or food allergies.
Family history
Mother: Deceased at age 60, throat cancer. History of hypertension.
Father: Deceased at age 70. Does not know cause of death.
Sister: Alive and well.
Brother: Alive and well.
Daughter: alive and well.
Social History
Ms. KM is a single female living with daughter.
Habits: Patient drinks 2-3 glass of wine per week. Patient denies past or present smoking, vaping or chewing tobacco. Patient denies history of illicit substance use.
Diet: Patient states having a well-balanced diet.
Travel: Patient denies any recent travel.
Exercise: Patient works as a housekeeper. She does not exercise as her work leaves her tired.
Safety measures: Admits to wearing a seatbelt, looking both ways before crossing the street.
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 – Patient states vertigo. Denies headaches, or head trauma.
Eyes – Denies other visual disturbances, or photophobia. Denies pruritus. She wears reading glasses. Last eye exam 2019– does not know her visual acuity.
Ears – Denies deafness, pain, discharge, tinnitus or use of hearing aids.
Nose/sinuses – Patient states epistaxis. Denies obstruction.
Mouth/throat – Patient states sore throat. Denies bleeding gums, sore tongue, mouth ulcers, voice changes or use dentures. Last dental exam 4 years ago- unremarkable.
Neck – States stiffness/decreased range of motion. Denies localized swelling/lumps.
Breast – Denies lumps, nipple discharge, or pain.
Pulmonary system – Denies dyspnea, dyspnea on exertion, cough, wheezing, hemoptysis, cyanosis, orthopnea, or paroxysmal nocturnal dyspnea (PND).
Cardiovascular system – Has a history of hypertension x 2yrs. Denies chest pain, irregular heartbeat, edema/swelling of ankles or feet, syncope or known heart murmur.
Gastrointestinal system – States dysphagia. Has regular bowel movements daily. Denies change in appetite, intolerance to specific foods, nausea, vomiting, pyrosis, unusual flatulence or eructation, abdominal pain, diarrhea, jaundice, hemorrhoids, constipation, rectal bleeding, or blood in stool. Patient has not done a colonoscopy or FOBT test.
Genitourinary system – Denies urinary frequency or urgency, nocturia, oliguria, polyuria, dysura, incontinence, awakening at night to urinate or flank pain.
Menstrual/Obstetrical – G1 T1 P0 A0 L1, no complications normal spontaneous vaginal delivery. Last menstrual period at age 46. Currently in menopause – patient has hot flashes. Denies breakthrough bleeding/spotting. Denies vaginal discharge or bleeding.
Nervous – Denies seizures, headache, loss of consciousness, sensory disturbances, ataxia, loss of strength, change in cognition / mental status / memory, or weakness.
Musculoskeletal system – States pain both knee joints and fingers. Denies any deformities and muscle pain.
Peripheral vascular system – Denies intermittent claudication, coldness or trophic changes, varicose veins, peripheral edema or color changes.
Hematological system – States easy brushing. Denies anemia, easy bleeding, lymph node enlargement, blood transfusions, or history of DVT/PE.
Endocrine system – Denies polyuria, polydipsia, polyphagia, heat or cold intolerance, excessive sweating, hirsutism, or goiter
Psychiatric: Denies Depression/sadness (Feeling of helpless, feeling of hopelessness, lack of interest in usual activities, suicidal ideation), anxiety, obsessive/compulsive disorder.
Physical
General – Not in distress, sitting up in bed, neatly-groomed and appropriately dressed. Alert and oriented to person, place, and time. Looks her stated age of 46.
VITAL SIGNS
BP R L
SEATED 130/90 125/92
SUPINE 120/85 125/80
Respiratory rate: 16 breaths/minute, unlabored
Pulse: 82 beats/ min, regular
T: 97.9 F, orally
O2 saturation: 97%, room air
Height: 5’5’’ weight: 121 lbs BMI: 20.1
Skin: Warm and smooth skin with good turgor, several 2 mm regular bordered nevi present on the right cheek. One 2 cm nodule present in left foot with pain on palpation. Nonicteric. No lesions, scars, or tattoos.
Hair: average quantity and distribution, good texture.
Nails: no clubbing, capillary refill <2 in both hands and feet. No paronychia.
Head: normocephalic, atraumatic, nontender to palpation throughout. No faces present.
Scalp: no scaling.
Ears: Symmetrical and good size. No scaling lesions, masses or trauma. Auditory acuity intact to whispered voice AU. No discharge, foreign bodies in external auditory canal AU. Tympanic membrane pearly grey, intact with light reflex in normal positions. Webbers midline. Positive Rinne AU. AC>BC.
Eyes – Symmetrical OU, No strabismus, exophthalmos, ptosis, edema, crusting, or discharge. Sclera white, cornea clear, conjunctiva pink. Pupils equal round reactive to light and accommodation. EOMs intact. Visual fields full OU. No crescent sign. Visual acuity uncorrected OS- 20/25, OD- 20/30 and OU – 20/20.
Fundoscopy: red reflex intact OU. No AV nicking, hemorrhages, or exudates OU. Cup to disc ratio <0.5 OU.
Nose: Symmetrical and normal size. No masses, lesions, deformities, trauma, or discharge. Nares patent bilaterally, nasal mucosa pink and well hydrated. Septum midline without any masses, lesions, or deformities. No foreign bodies.
Sinuses: nontender to palpation over bilateral frontal and maxillary sinuses. Positive transillumination of sinuses.
Mouth and Pharynx:
Lips: Pink, moist, no cyanosis, lesions or masses.
Mucosa: Pink, well hydrated. No masses or lesions, nontender to palpation.
Palate: Pink, well hydrated. No masses, lesions or scar. Nontender to palpation, continuity intact.
Teeth: no dental caries, or loose tooth.
Gingivae: Pink and moist. No lesions or masses.
Tongue: pink, well papillated, No lesions or masses.
Oropharynx: Well hydrated. No exudates, masses, lesions or foreign bodies. Tonsils present, no swelling, injection, or exudates present. Uvula pink and rises symmetrically on phonation. No edema.
Neck: No cyanosis, erythema, masses, lesions or scars noted. Trachea midline. Nontender, nonpalpable masses on thyroid, no thyromegaly.
Thorax and lungs:
Chest: Symmetrical, no deformities or evidence of trauma. No use of accessory muscle noted, lat to AP diameter 2:1. Non tender to palpation.
Lungs: Clear to auscultation and percussion bilaterally. Symmetrical chest expansion and diaphragmatic excursion. Tactile fremitus symmetric throughout. No adventitious sounds.
Abdomen: Abdomen flat and symmetrical with no scars, striae or pulsations. Unremarkable bowel sounds in all four quadrants with no aortic/ renal/iliac or femoral bruits. Non tender to palpation throughout. No rebound tenderness, no Psoas sign, no obturator sign. No hepatosplenomegaly and no CVA tenderness noted.
Heart: Jugular Venous Pressure is 2.5 cm above the sternal angle with the head of the bed at 30°. PMI in 5th Intercostal Space in mid-clavicular line. Carotid pulses are 2+ bilaterally without bruits. Regular rate and rhythm (RRR). S1 and S2 are distinct with no murmurs, S3 or S4. No splitting of S2 or friction rubs noted.
