History

Identifying Data:

Full Name: Ms. AP

Address: Queens, NY

Date of Birth: 12/2/1942

Date & Time: September 1, 2020, 9:30 am

Location: NYHQ, Flushing, NY

Religion: Catholic

Source of Information: Self

Reliability: Reliable

Source of Referral: Primary Care Physician

Mode of Transport: car

 

Chief Complaint: “I am getting cleared for my right knee replacement surgery”

 

History of Present Illness:

77-year-old female with PMH of arthritis, hypercholesteremia, allergic rhinitis and Raynaud’s phenomenon, and a significant surgical history of left knee replacement surgery without complications presents to preadmission testing to get cleared for right knee replacement. Patient was diagnosed with arthritis at age 57 which causes her knee and shoulder joint pain. She recalls both her knees hurting for the first time after a fall on the streets 20 years ago that did not lead to any significant injury. Her knee pain continued since then and has gotten worse. She had been receiving corticosteroid injections for her pain for 5 years without much relief making her require both knee replacement.  She rates the pain as 8/10 and states it is constant. It is worsened by walking and worsens as the day progresses but not alleviated by rest – confining her to her home. The pain does not radiate anywhere. She states arthritis, knee, shoulder joint pain, and loss of strength. She denies muscle, deformity, swelling, redness, or weakness. She denies fever, chills, weightless, sensory disturbances, ataxia, or change in cognition. She states feeling a little lonely at times but denies depression/sadness, anxiety, OCD or ever seeing a mental health professional

 

Past Medical History:

Arthritis 20 years

Hypercholesteremia 2 months

Allergic rhinitis 47 years

Raynaud’s phenomenon (years)

 

Denies any Childhood illnesses

Immunizations – patient did not receive her flu shot yet

 

Past Surgical History:

Right Inguinal hernia repair – age 75, NYP-QUEENS, NY. no complications.

Left knee replacement – age 76, NYP-QUEENS, NY., no complications.

Denies past injuries or blood transfusions.

Denies history of other surgeries.

 

Medications:

Atorvastatin 10mg (Zestril), 1 tab PO daily for hypercholesteremia, last dose this morning

Ipratropium bromide 0.06% nasal spray. 3x a day 2 spray on each nose as needed. Last dose 2 days ago.

Vitamin D3 2000 IU 1 tab PO daily, last dose this morning

Calcium 600 mg 1 tab PO daily, last dose this morning

Denies use of herbal supplements

Allergies:

No known food or drug allergies

 

Family History:

Mother – Deceased at age 63, stroke

Father – Deceased at age 78, liver cancer

Three Daughters – alive and well [age]

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

 

Social History:

Ms. P is a widowed female who lives alone at home. Her daughters help her with groceries and with travel to her appointments.

Habits – She denies past and present tobacco use.  Denies history of substance abuse, denies history of illicit substance use.  She drinks two cups of coffee every day. Denies any alcohol use.

Travel – No recent travel.

Diet – She has a well -balanced diet with fruits and vegetables. She tries to increase her fiber intake.

Exercise – She is unable to exercise due to her knee pain. She cannot walk more than one block.

Safety measures – Admits to wearing a seat belt.

Sexual Hx – Heterosexual, is not sexually active since her husband’s passing 5 years ago. 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]

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

Nose/sinuses – Denies discharge, obstruction or epistaxis.

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

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

Breast – Denies lumps, nipple discharge, or pain. Last mammogram: December 2018, no significant findings.

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. [colonoscopy/FOBT: date and finding]

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

Menstrual/Obstetrical – G3P3 (NSVD x 3, no complications. Menarche age 13. LMP at age 52. Currently in menopause – denies hot flashes or associated menopausal symptoms. Denies breakthrough bleeding/spotting or vaginal discharge.

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

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

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 – States feeling lonely sometimes. Denies feeling hopeless or helpless, anxiety, OCD or ever seeing a mental health professional.

 Physical

 General:  77-year-old female, alert and oriented x3, Slender, neatly groomed, looks her stated age of 77 years. In no apparent distress.

Vital Signs:     BP:                              R                     L

Seated             139/69             140/70

Supine             135/72             136/78

R:        16/min unlabored                    P: 67, regular

 

T:        97.8 degrees F (oral)               O2 Sat: 96% Room air

 

Height: 5 feet Weight 101 lbs.    BMI: 19.7

PHYSICAL EXAM:

Skin: cool skin with poor turgor. 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 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. Pupils equal round reactive to light and accommodation.  EOMs intact. 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: patient uses dentures, 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: Pectus carinatum, no evidence of trauma. No use of accessory muscle noted, lat to AP diameter not 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 commands She 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 4/5 throughout.  Rhomberg negative, no pronator drift noted. Gait steady with no ataxia. 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.

Assessment: 77-year-old female with a PMH of arthritis, hypercholesteremia, Raynaud’s phenomenon presenting to preadmission testing to get cleared for right knee replacement.

• Differential Diagnosis
  • Post traumatic arthritis: patient states falling on both and hurting both her knees which may have caused her osteoarthritis. She was also refractory to treatment.
  • OSTEOARTHTITIS: Knee joint degeneration causing pain that was refractive to nonoperative treatment. She has increased risk factor – age and female. She also states joint pain.
  • Spontaneous osteonecrosis of the knee (SONK): SONK is a cause of acute, unilateral knee pain and swelling due to insufficiency fracture. Due to her advanced age she may have had insufficiency fracture to both her knees. Patients with SONK are usually over 50-year-old and women.
  • Bone tumor: Bone tumors can damage the knee joint that may require patients to get knee replacement surgery.
  • Inflammatory arthritis: Rheumatoid arthritis may increase the risk of osteoarthritis that may lead to needing surgery if pain is not controlled by nonsurgical methods.

Very good!