H&P – 1

by Sierra Teegarden

This is my first History & Physical which was taken & performed in the Pre-Admission Testing unit. This assignment is apart of Physical Diagnosis I.

*Patient identifiers & personal details, including but not limited to the dates listed below, have been modified for patient privacy.

IDENTIFICATION:

Patient encounter 9:00am 04/13/2021

Name: J.H.

DOB: 01/01/1966

Sex: female

race: Hispanic

nationality: unknown

Age: 55

marital status: divorced

address: unknown

religion: unknown

INFORMANT

Source of the history: self, reliable

REFERAL SOURCE

Orthopedics

CHIEF COMPLAINT

Surgery clearance for right knee arthroscopy after falling on it in 2018

HISTORY OF PRESENT ILLNESS

J.H., 55 y/o G2P2 female, presents to preadmission testing to get clearance for an arthroscopic meniscus repair of the right knee scheduled for April 3, 2021. No known prior/current Covid-19 infection, next test scheduled for March 30th, 2021. She states she first experienced abrupt right knee pain after falling down a flight of 8-9 stairs at the movie theatre in 2018. At the time of the fall, she also injured her right shoulder and is currently receiving physical therapy for both joints. The pain in her knee started as intermittent but has become progressively worse since then and is now a constant, dull, throbbing pain, rated 6-7/10 without medication. Excessive use of the joint makes the pain worse. Tylenol (x2 tablets OTC) relieves the pain for a short duration. Ibuprofen works better than Tylenol, but she does not take it frequently because she states it is worse for her kidneys. She exercises every day but is unable to do certain movements or walk for prolonged periods of time due to the pain and limited range of motion. Her right shoulder pain is also constant but not as severe and is controlled by the physical therapy. She experienced right-sided weakness several years prior and has been followed by neurology and cardiology since then. She states TIA/stroke were ruled out by neuro, but cardiology found a “small blockage in her heart” which is now treated with Clopidogrel & Atorvastatin. Pertinent current medical conditions include Coronary Artery Disease, Diabetes Mellitus Type 2, postsurgical hypothyroidism secondary to thyroidectomy, and cholelithiasis (diet controlled). No other abdominal issues, hepatitis/fatty liver, or hypertension. Dentition intact other than dental bridge. No sleep apnea reported, STOP-BANG score of 2.

PAST MEDICAL HISTORY

  • Current medical illnesses:
    • Diabetes Mellitus Type 2 – duration unknown
    • Coronary Artery Disease – 3 years
    • Postsurgical hypothyroidism secondary to thyroidectomy – “several years ago”
    • Cholelithiasis – 2019 (well controlled by diet modifications since then)
    • Allergic Rhinitis – “entire life”
    • Symptomatic Menopausal state – 3 years prior
  • Past medical illnesses:
    • Goiter – “several years ago”
  • Hospitalizations and reason for hospitalizations
    • None other than those listed in surgical history
  • Childhood illnesses
    • Varicella Virus – “as a child”
  • Immunizations:
    • Up to date
    • Covid vaccination – status unknown
  • Screening test and results
    • A1c – 7.1
    • TSH – unknown (checked recently and Levothyroxine dosage adjusted based on result)
    • Covid-19 PCR – Test scheduled for 03/29/2021
    • STOP-BANG Score for Obstructive Sleep Apnea – 2
    • CT/CXR – “small” lung nodules (attributed to secondhand smoke from childhood)
    • EKG – unremarkable per pt (last performed 09/2020)
    • Echo & Stress test – unremarkable per pt (last performed 2018 or 2019 per pt)

PAST SURGICAL HISTORY

  • Past surgical procedures / date / hospital / reason
    • Thyroidectomy – “several years ago”
    • Cesarean Section x2 (1st – 1995, 2nd – unknown date)
  • Past injuries-what/when/where
    • None prior to current right knee and right shoulder injury status post fall
  • Transfusions
    • none
  • Complications of surgical procedures:
    • 1st cesarean section – “didn’t go completely under during anesthesia”
    • 2nd cesarean section – “prolonged wake up time”
    • Thyroidectomy – no complications

MEDICATIONS

  • Semaglutide (Ozempic) – 1mg/week SubQ   
  • Metformin – 1000mg twice daily PO
  • Atorvastatin – 10mg daily PO
  • Clopidogrel – 75 mg daily PO
  • Levothyroxine – 112 mcg daily PO
  • Allegra – daily PO (during Spring – fall months)
  • Azelastine – daily Intranasal (during spring – fall months)
  • Vitamin D – OTC daily PO

ALLERGIES

NKDA / no food allergies / seasonal environmental allergies (well controlled with medication)

FAMILY HISTORY

FAMILY HISTORY

  • Mother – Unstable Angina (living, 92 y/o)
  • Father – deceased from stroke (age unknown “when he was younger”)
  • Maternal Grandmother – deceased from MI (age unknown)
  • Maternal Grandfather – unknown
  • Paternal Grandmother – unknown
  • Paternal Grandfather – unknown
  • Aunt – MI (“deceased of massive heart attack at a young age”)
  • Children – 2 children alive and healthy

SOCIAL HISTORY

  • Habits – drinking alcohol socially, no smoking, no drug use, drinking caffeine
  • Travel – no recent travel
  • Marital history – divorced
  • Occupational history – Job Recruiter
  • Home situation – living with both children (son and daughter), no pets
  • Diet – Following a low sugar, low fat diet
  • Sleep patterns – sleeping well throughout the night
  • Exercise – exercising daily, performing exercises learned in physical therapy
  • Safety measures – wearing seatbelt
  • Sexual History – not currently sexually active

REVIEW OF SYSTEMS

  • General
    • recent weight loss (intentional as a result of lifestyle modifications)
    • denies loss of appetite, generalized weakness/fatigue, fever/chills, or night sweats
  • Skin, hair and nails
    • denies changes in texture, excessive dryness or sweating, discolorations, pigmentations, moles/rashes, pruritus, or changes in hair distribution
  • Head
    • denies headaches, vertigo, light-headedness, or head trauma
  • Eyes
    • denies visual disturbance (include recent blurring, diplopia, fatigue with use of eyes, scotoma, or halos), abnormal lacrimation, photophobia, pruritus
    • last eye exam performed “a few weeks prior” with no abnormalities aside from age-related vision loss per patient. Pt denies having diabetic retinopathy
    • Wearing Glasses – “no issues” with corrected vision
  • Ears
    • Denies deafness, pain, discharge, tinnitus
    • Not using hearing aids
  • Nose/Sinuses
    • Recent clear mucous discharge, congestion, and sore throat (attributed to seasonal allergies)
    • No epistaxis or obstruction
  • Mouth and throat
    • Denies, bleeding gums, sore tongue, mouth ulcers, or voice changes
    • Admits to having dental bridge
    • Receives annual dental exams
  • Neck
    • Denies swelling/lumps or stiffness/decreased ROM
  • Breast
    • Denies lumps, nipple discharge, or pain
    • Last mammogram unknown
  • Pulmonary System
    • Denies dyspnea/DOE, cough, wheezing, hemoptysis, cyanosis, orthopnea, or PND
  • Cardiovascular System
    • Palpitations (Attributed to levothyroxine dosage – recently adjusted and no palpitations since)
    • Denies chest pain, Hx of HTN, Irregular heartbeat, edema/swelling of ankles or feet, or syncope
    • No known heart murmurs 
  • Gastrointestinal System
    • Intolerance to fatty foods (Worsens Cholelithiasis)
    • Denies changes in appetite, N/V/D, dysphagia, pyrosis, abnormal flatulence, eructation, abdominal pain, jaundice, change in bowel habits, hemorrhoids, constipation, rectal bleeding, or blood in stool
    • Last stool guaiac test/colonoscopy/sigmoidoscopy unknown
  • Genitourinary System
    • Denies changes in frequency, nocturia, urgency, oliguria, polyuria, dysuria, abnormal color of urine, incontinence, or flank pain
  • Sexual History
    • Not currently sexually active
    • Past sexual partners – male
    • Past sexually transmitted infections – unknown
  • Menstrual and Obstetrical
    • date of last normal period – 2018
    • Denies abnormal vaginal discharge
    • Menopause
    • G2P2200 x2 cesarean
  • Nervous System
    • Denies seizures, headache, loss of consciousness, sensory disturbances (numbness, paresthesias, dysesthesias, or hyperesthesias), ataxia, loss of strength, change in cognition/mental status/memory, or weakness
  • Musculoskeletal System
    • Right knee pain, Right Shoulder pain. Decreased ROM of right knee. Lower back pain
    • Denies swelling/redness over the joints
    • Denies history of arthritis/osteoarthritis
  • Peripheral Vascular System
    • Denies intermittent claudication, coldness/trophic changes, varicose veins, peripheral edema, or changes in color
  • Hematologic System
    • Denies anemia, easy bruising or bleeding, lymph node enlargement, prior blood transfusions, or Hx of DVT/PE
  • Endocrine System
    • Denies polyuria/polydipsia/polyphagia
    • Denies cold intolerance or hirsutism
    • Goiter removed “several years prior”
    • Admits to excessive sweating and heat intolerance (attributed to hypothyroidism & menopause)
  • Psychiatric
    • Denies depression/sadness, feelings of helplessness, feelings of hopelessness, lack of interest in usual activities, suicidal ideations, anxiety, or obsessive/compulsive disorder
    • Denies ever seeing a mental health professional or taking psychiatric medications

PHYSICAL EXAM

Vital Signs:

BP: 126/70 mmHg

*BP obtained from patient’s chart because my manual blood pressure cuff did not fit patient’s arm

RR: 15 breaths/min, unlabored

Pulse: 85 bpm, regular

T: 98.0 F (oral)

                        *Obtained from patient’s chart

O2 SAT: 96% room air

                        *Obtained from patient’s chart

            Height: 67 inches        Weight: 247 lbs.          BMI: 38.7

General Appearance: alert, not distressed, appropriate development, obese, well nourished, appropriate posture, appears stated age, well dressed

Head: normocephalic, atraumatic, non-tender to palpation throughout

Eyes: Symmetrical OU. No strabismus/exophthalmos/ptosis. Sclera white, cornea clear, conjunctiva pink. No erythema of lacrimal sack. Visual acuity test not performed. Visual fields full OU. PERRL. Accommodation not performed. EOM intact with no nystagmus. Red reflex intact OU. Retinal vessels unremarkable. Unable to visualize optic disc/macula/fovea.

Ear: Appropriate in size. Ear and tragus nontender AU. No lesions/masses/trauma visualized on external ear. No discharge/foreign bodies in external auditory canals AU. TM pearly white/intact with cone of light in appropriate position AU. Appropriate amount of cerumen noted. Auditory acuity intact to whisper voice AU. Weber midline / Rinne AC>BC AU.

Nose: Symmetrical, no masses/lesions/deformities/trauma/discharge. Nares patent bilaterally. Nasal mucosa pink & well hydrated. Septum midline. Anterior rhinoscopy not performed.

Sinuses: No tenderness to palpation over bilateral maxillary/ethmoid/frontal sinuses.

Lips: pink, moist, no cyanosis or lesions. Palpation not performed

Mucosa: Pink, well hydrated. No masses/lesions noted. No leukoplakia. Palpation not performed.

Palate: Pink, well hydrated. No visible lesions/masses/scars. Palpation not performed.

Teeth: No obvious dental caries noted. Dental bridge, otherwise good dentition.

Gingivae: not visualized or palpated

Tongue: pink, well papillated. No masses/lesions/deviation. Not palpated

Oropharynx: Well hydrated, no exudate/masses/lesions/foreign bodies noted. Unable to visualize tonsils. Uvula pink, midline with no lesions or edema.

Neck: Trachea midline. No masses/lesions/pulsations noted. Midline horizontal scar from prior thyroidectomy noted. Supple, non-tender to palpation. Free range of motion. No stridor noted. No cervical adenopathy. Did not palpate/auscultate for carotid pulses/thrills/bruits.

Thyroid: not present (prior thyroidectomy)

Lymph nodes: Non-palpable, unremarkable preauricular, postauricular, submandibular, posterior cervical chain, anterior cervical chain, supraclavicular, and infraclavicular lymph nodes

Skin: Warm and moist, good turgor. Non-icteric, no lesions/scars/tattoos noted. Appropriate thickness and texture

Hair: Average quantity and distribution. No seborrhea/lice/dandruff noted

Nails: Upper extremity: No clubbing, capillary refill <2 seconds in upper extremity, appropriate shape & color. Lower extremity nails not visualized.