History

Identifying Data:

Full Name: Mrs. LD

Address: Queens, NY

Date of Birth: 04/24/1987

Date & Time: September 22, 2020, 8:00 am

Location: NYHQ, Flushing, NY

Religion: Catholic

Source of Information: Self

Reliability: Reliable

Source of Referral: self

Mode of Transport: walk

Chief Complaint: “I tripped and fell when running after a bus” x 3 hours

History of Present Illness:

33-year-old female with no significant PMH presents to the ER with left knee pain and abrasions on her left palm and left knee after falling while running to catch a bus to go to work three hours ago. She states she tripped and fell without any precipitating factors. She landed on her left knee and left wrist and got up as soon as she fell and walked to the hospital. She has no pain on her left wrist but states a non-radiating pain upon palpation over her left patella which she rates as a 6/10. She did not take anything to alleviate her pain. She walked herself to the hospital in order to clean the wounds before returning back to work. Pressure aggravates her pain. She denies any dizziness, loss of consciousness, trauma to the head. Denies headache, sweating, fever, fainting, lightheadedness, SOB, PND, orthopnea or loss of consciousness She denies any other joint pain, loss of strength, deformity, swelling, or weakness. She denies sensory disturbances, ataxia, or change in cognition.

Past Medical History: No significant PMHx

Denies any Childhood illnesses

Immunizations – patient did not receive her flu shot yet, others up to date. Tetanus vaccine – 12/2019

Past Surgical History:

Denies any surgeries

Denies past injuries or blood transfusions.

Medications:

Denies use of medication or herbal supplements.

Allergies:

No known food or drug allergies

Family History:

Mother – Alive and well, fibroids

Father – Alive and well.

One Daughters and Two son – alive and well [age]

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

Social History:

Mrs. D is a married female who lives with her three children and her husband. She works as a medical biller.

Habits – She denies past and present tobacco use.  Denies history of substance abuse, denies history of illicit substance use.  She drinks one cups of coffee every day. She mentions drinking occasionally during family gatherings around1-2 glasses of wine every 2-3 months.

Travel – No recent travel.

Diet – She has a well -balanced diet.

Exercise – She states exercising every day.

Safety measures – Admits to wearing a seat belt.

Sexual Hx – Heterosexual, her husband is her only partner. Uses condoms as her only source of contraception.  Denies history of Sexually transmitted diseases.

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 – Denies headaches, vertigo or head trauma.

Eyes – Denies any visual disturbances, or photophobia. She wears glasses. Last eye exam: 04/24/2020

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

Nose/sinuses – Denies discharge, obstruction or epistaxis.

Mouth/throat –Denies bleeding gums, sore tongue, sore throat, mouth ulcers or voice changes. Denies use of dentures. [Last dental exam]

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

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 – Denies chest pain, HTN, irregular heartbeat, edema/swelling of ankles or feet, syncope or known heart murmur

Gastrointestinal system – Has regular bowel movements daily. Denies change in appetite, intolerance to specific foods, nausea, vomiting, dysphagia, pyrosis, unusual flatulence or eructation, abdominal pain, diarrhea, jaundice, hemorrhoids, constipation, rectal bleeding, or blood in stool.

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

Menstrual/Obstetrical – Currently menstruating. G3P3 (NSVD/Cesarean? complications?)  Can write unknown instead of question marks.

Nervous – Denies seizures, headache, loss of consciousness, sensory disturbances, ataxia, loss of strength change in cognition / mental status / memory, or weakness.

Musculoskeletal system – States left knee pain upon palpation. Denies muscle, deformity or swelling, redness, arthritis, and shoulder joint pain.

Peripheral vascular system – Denies intermittent claudication, coldness or trophic changes, varicose veins, peripheral edema or color changes.

Hematological system – Denies anemia, easy bruising or 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 feeling hopeless or helpless, anxiety, OCD or ever seeing a mental health professional.

Physical

General: 33-year-old female, alert and oriented x3, Slender, neatly groomed. In no apparent distress. Good, I’ll add a little more.  Gait? Appears stated age?

 

Vital Signs:     BP:                              R                     L

Seated             125/86             126/80

Supine             125/84             128/82

 

R:        22/min unlabored                    P: 77, regular

 

T:        97.8 degrees F (oral)               O2 Sat: 97% Room air

 

Height: 5 feet Weight 101 lbs.    BMI: 19.7

PHYSICAL EXAM:

Skin: warm skin with good turgor. Nonicteric. 2 cm abrasion on left palm and 3 cm abrasion on left knee. No scars, or tattoos.

Hair: average quantity and distribution, good texture.

Nails: No clubbing, capillary refill <2 in both hands and both 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 GOOD 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. EOMs intact. Pupils equal round reactive to light and accommodation. Visual fields full OU. No crescent sign. Visual acuity corrected 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.

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: No 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.

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.

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.

Genitalia: External genitalia without erythema or lesions. Vaginal mucosa pink without inflammation, erythema or discharge. Cervix multiparous, pink, and without lesions or discharge. No cervical motion tenderness. Uterus anterior, midline, smooth, non-tender and not enlarged. No adnexal tenderness or masses noted. Pap smear obtained. No inguinal adenopathy.

RECTAL: Rectovaginal wall intact. No external hemorrhoids, skin tags, ulcers, sinus tracts, anal fissures, inflammation or excoriations. Good anal sphincter tone. No masses or tenderness. Trace brown stool present in vault. FOB negative.

Breast: Symmetric, no dimpling, no masses to palpation, nipples symmetric without discharge or lesions.  No axillary nodes palpable

Mental status:

Patient is alert, and appropriately dressed. No tics or abnormal behavior. Patient is happy and friendly. Follows two stage commandsShe is talkative, with good rate and volume. Clear speech and even rhythm. Denies having thoughts of harming self or other, trouble controlling temper and constantly worrying. No abnormal flight of ideas. Has no hallucinations, delusions or obsessions. Has good insight and proper judgement. Good memory, attention and cognitive functions.

Cranial nerve:

CN I: Olfactory – can perceive orders on both sides and identify them correctly

CN II OPTIC – Visual fields full, visual fields 20/20 OD, OS and OU, corrected.

CN III (Oculomotor), IV (Trochlear) and VI (Abducens) – EOMs intact pupils 3 mm OU, PEERLA, no ptosis

CN V (trigeminal) – facial sensation intact bilaterally to light touch and pain, intact corneal reflex, strong contractions of jaw muscles

CN VII (facial) and CN IX (Glossopharyngeal) – Intact taste to sweet, salt, sour and bitter. Symmetric and fluid facial movements. No difficulty with bmp sounds. Strong eye muscles that hold the eyes closed.

CN VIII (acoustic) – Weber midline and Rinne reveals AC>BC. Can repeat whispered words at 2 feet.

CN IX (Glossopharyngeal) and CN X (VAGUS) – no hoarseness, uvula midline with elevation of soft palate, gag reflex intact, no difficulty swallowing.

CN XI (SPINAL ACCESSORY) – full range of motion at neck with 5/5 strength and strong shoulder shrug.

CN XII (HYPOGLOSSAL) – Strong and symmetrical tongue. No difficulty with Ltnd speech sounds

Peripheral nervous exam:

Motor/Cerebellar

Full active/passive ROM of all extremities without rigidity or spasticity. Symmetric muscle bulk with good tone. No atrophy, tics, tremors or fasciculation. Strength 5/5 throughout.  Rhomberg negative, no pronator drift noted. Slight limp on left leg. Tandem walking and hopping show balance intact. Coordination by rapid alternating movement and point to point intact bilaterally, no asterixis

Sensory

Intact to light touch, sharp/dull, and vibratory sense throughout.   Proprioception, point localization, extinction, stereognosis, and graphesthesia intact bilaterally

Reflexes 2+ throughout, negative Babinski, no clonus appreciated.

Peripheral vascular exam:  

The extremities are normal in color, size and temperature. Pulses are 2+ bilaterally in upper and lower extremities. No bruits noted. No clubbing, cyanosis or edema noted bilaterally. No stasis changes or ulcerations noted.

Musculoskeletal exam [part 1]:

Pain upon palpation over the left knee with a 3 cm abrasion without swelling or stiffness. A 2 cm abrasion the palmar side of the left hand, no atrophy, deformities. No tenderness over the anatomic snuffbox. No pain upon flexion, extension of the hand and the wrist. Good AROM and PROM of the knee. Negative Phalen test and Tinel’s sign. No scoliosis, No pain upon palpation of the shoulder, no atrophy, no ecchymosis or venous pattern. Good AROM and PROM.

Very Good!

Assessment: 33-year-old female with no significant PMH presenting to ER after a trip and fall.

• Differential Diagnosis
  • Mechanical Fall: Patient likely had a mechanical fall as she was running after a bus. There were no symptoms before her fall, and she did not lose consciousness. She does not take any medications and denies history of alcohol use.
  • Alcohol use: Can cause impairment of balance leading to falls. It is however unlikely for this patient as she was not intoxicated, and states use of alcohol only on special occasions.
  • Use of benzodiazepine or sedative/hypnotic agent: Although these agents may cause drowsiness, dizziness and confusion increasing the risk of falls patient denies any history of medication use and did not present with any symptoms before the fall.
  • Syncope: Patients with syncope can present with sudden fall due to many factors such as hypoglycemia, narcolepsy, medications etc. However, it is not the case for this patient since the patient did not lose consciousness, does not take any medications, has no history of medical illness.
  • Impairment of balance: Any head injury, ear infections, peripheral neuropathy etc. can cause impairment of balance in patients. Patient has no history of trauma, no other symptoms associated with her fall and good tandem gait making it very unlikely that her balance is impaired.

Plan?

Excellent Job!