The following History & Physical was obtained from my third hospital visit in the Emergency Department:
*Areas marked in red were either not performed/obtained or were obtained by hospital staff but have been written in to show completeness of findings I would document in a complete H&P.
Full Name: X.D.
Date & Time: 09:00AM 05/18/2021
Location: NYPQ Hospital
Marital status: Married
Address: Queens, NY
Source of Information: Self with Mandarin translation services
Source of Referral: Cardiology
Chief Complaint: “I am having the worst chest pain, back pain, and difficulty breathing that I have ever had” x2 weeks
History of Present Illness:
68 y/o covid-19 negative female with HTN, Leukemia, & Hx of MI (27 yrs prior, no stents) was admitted to the ED this morning with complaints of persistent chest pain radiating to her back, palpitations/racing heart, and concerns over her elevated blood pressure that abruptly began 2 weeks prior after getting the covid vaccine, which she attributes as the cause. She expresses concern that her HR is normally around 58 bpm and is now 78 bpm which she believes to be “really fast”. She describes the chest pain as feeling “heavy” with “something stuck on her chest”. She points to the area of pain being located under her left breast tissue and posteriorly across her cervical spine. She cannot quantify the pain into a number on the pain scale but states she has gone into the hospital every year for 20 yrs with this pain and this time is the “worst chest pain she has ever had”. She states every time she goes into the hospital, they “treat her heart” but she is unsure of what interventions or diagnosis have been given. Walking and taking deep breaths on inspiration makes the pain worse. Sitting down helps to relieve Sx. She states her BP was 203/98 at the onset of Sx but after having her “heart medicine changed by her cardiologist from 40mg to 100mg it has come down to 153/something” She is also taking a “Chinese herb” that she believes is helping her Sx. Her cardiologist performed a sonogram on her at that time, but she is unsure of the results. Other accompanying symptoms include SOB, DOE, fatigue, orthopnea (sleeps sitting up), PND, swelling of the R ankle/foot, right eye pain, dizziness, and sweating. She denies fever, N/V, syncope, wheezing, cough, hemoptysis, cyanosis, or calf pain. She hears a “buzzing” in her R ear but denies a pulsatile sound. Translation service was used for today’s encounter & the pt was accompanied by her spouse.
Past Medical History:
- Present illnesses:
- Hypertension – Dx 1994
- Leukemia – Dx 2018
- Past illnesses:
- Anterior Wall Myocardial Infarction – Dx 1994
- Childhood illnesses: none known
- Up-to-date on immunizations
- Covid-19 vaccine – 2nd dose given 2 weeks prior
- Prior Hospitalizations
- 1x/yr for the past 27 yrs for chest pain. All prior hospitalizations were in China per pt.
Past Surgical History:
- No prior surgeries
- No past injuries
- No prior transfusions
- No complications of surgical procedures
- Losartan PO, 1x/daily (unable to obtain dose)
- Hypertension – last dose this morning
- Metoprolol PO, 1x/daily (unable to obtain dose)
- Hypertension – last dose this morning
- Zolpidem PO, 1x/daily at night (unable to obtain dose)
- Insomnia – last dose last night at 2am
- Clonidine PO 1x/daily (unable to obtain dose)
- Hypertension – last dose this morning
- Aspirin PO 81mg 1x/daily
- CAD – prior MI
- Monoclonal antibody (unable to obtain specific drug name, dose, route, & interval)
- Leukemia – last dose unknown
- “Chinese Herb” (unable to obtain dose, route, interval)
- Last dose this morning
- NKDA, no known food/environmental allergies
- Mother – “heart problems”, HTN. Deceased at 79 y/o unknown cause
- Father – HTN, DM Type 2. Deceased at 68 y/o unknown cause
- Maternal Grandmother – unknown
- Maternal Grandfather – unknown
- Paternal Grandmother – unknown
- Paternal Grandfather – unknown
- Brother – “heart problems”, 60 y/o, living (youngest sibling)
- Sister 1 – “heart problems”, alive
- Sister 2 – “heart problems”, alive
- Sister 3 – “heart problems”, alive
- Sister 4 – “heart problems”, alive
- Sister 5 – “heart problems”, alive
- Sister 6 – “heart problems”, alive 80 y/o (oldest sibling)
- Denies ever using alcohol, tobacco, drugs
- Caffeine – 1 cup coffee/day
- Travel – No travel since COVID-19. Prior to that, traveled to China every year.
- Occupation – No prior work history
- Marital History – Married
- Living situation – Living with spouse, no pets
- Diet – No dietary restrictions. Eating 3 meals per day. States she mainly eats foods “from china”.
- Sleeps in the upright position to “breath better”. Wakes up every 2 hrs and takes a “sleeping pill” to fall back asleep.
- Exercise – Not exercising. States that walking normally “sucks all the energy out of her” and she has trouble walking at all now in the past 2 weeks.
- Safety measures – wearing seatbelt
- Sexual History – Sexually active with men. Monogamous with male spouse. Denies anorgasmia, impotence. No Hx of STIs. Not using contraception.
Review of Systems:
- Admits to generalized weakness/fatigue. Denies recent weight loss/gain, loss of appetite, fever/chills/night sweats
- Skin, hair, nails
- Admits to diaphoresis. Denies pigmentations, moles, change in hair distribution, xerosis, rash, or erythema
- Admits to vertigo. Denies headache or head trauma
- Admits to eye pain OD. Denies abnormal lacrimation, photophobia, or pruritis
- No prior eye exams. Visual acuity unknown. Not wearing glasses.
- Tinnitus in R ear.
- Denies hearing loss, pain, discharge, or feeling of fullness. Not using hearing aids.
- Denies epistaxis, congestion, or discharge
- Mouth and Throat
- Denies bleeding gums, sore tongue/throat, mouth ulcers, voice changes, or dentures. Last dental exam 04/2021, unremarkable per pt
- Denies swelling/lumps, stiffness, or decreased ROM
- Denies lumps, nipple discharge, or pain. Last mammogram unknown.
- Pulmonary System
- Admits to SOB, DOE, orthopnea, and PND. Denies cough, wheezing, hemoptysis, or cyanosis.
- Cardiovascular System
- Admits chest pain, palpitations, irregular heartbeat, edema/sweating
- Denies syncope or known heart murmur.
- Gastrointestinal System
- Denies changes in appetite, intolerance to specific foods, N/V/D, dysphagia, pyrosis, flatulence, abdominal pain, jaundice, changes in bowel habits, hemorrhoids, constipation, rectal bleeding/blood in stool, or constipation. Never had stool guaiac/colonoscopy/sigmoidoscopy
- Genitourinary System
- Denies changes in frequency, nocturia, urgency, oliguria, polyuria, dysuria, abnormal color of urine, incontinence, or flank pain
- Sexual History – refer to Social Hx
- LMP at 53 y/o. Postmenopausal. G1P1001. Last Pap Smear unknown.
- Denies postcoital bleeding, abnormal vaginal discharge, or dyspareunia
- Nervous System
- Admits to sensory disturbances – Paresthesia over the posterior cervical column
- Denies seizures, headache, loss of consciousness, ataxia, loss of strength, change in cognition/mental status/memory/weakness
- Musculoskeletal System
- Denies muscle/joint pain, deformity, swelling, redness, or Hx of arthritis
- Peripheral Vascular System
- Admits to peripheral edema over the right lower extremity x3 days but improved today
- Denies intermittent claudication, coldness/trophic changes, varicose veins, or color change
- Hematologic System
- Denies anemia, easy bruising/bleeding, lymph node enlargement, prior blood transfusions, or history of DVT/PE
- Endocrine System
- Admits to diaphoresis at onset of other Sx
- Denies polyuria/polydipsia/polyphagia, heat/cold intolerance, goiter, or hirsutism
- Denies current depression/sadness, anxiety, or obsessive/compulsive disorder. Denies ever seeing a mental health professional or taking psychiatric medications.
BP: 140/80 mmHg – sitting, L arm (R arm deferred due to IV placement)
RR: 12 breaths/min, unlabored
Pulse: 63 bpm, regular
T: 98.5 F (oral)
O2 SAT: 99% room air
Height: 67 inches Weight: 186 lbs. BMI: 30.0
General Appearance: alert & oriented. Moderately distressed. Appropriate development, 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. Corrected visual acuity 20/20 OU. Visual fields full OU. PERRLA. EOM intact with no nystagmus. Red reflex intact OU. Retinal vessels unremarkable (no AV nicking, hemorrhages, exudates, or neovascularization). Optic disc unremarkable (cup-to-disc ratio < 0.5 OU with appropriate color & contour), no papilledema. Macula & fovea unremarkable, no macular degeneration
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. Non-obstructing cerumen noted in the ears bilaterally. Auditory acuity intact to whisper voice AU. Weber midline / Rinne AC>BC AU.
Nose: Symmetrical, no masses/lesions/deformities/trauma/discharge. No tenderness/bogginess/step off to palpation. Nares patent bilaterally. Nasal mucosa pink & moist. Septum midline. Inferior nasal turbinate unremarkable and clear mucus visualized on anterior rhinoscopy. No ulcerations/foreign bodies visualized.
Sinuses: No tenderness to palpation over bilateral maxillary/frontal sinuses.
Mouth & Throat:
Lips: Pink & moist. No cyanosis, lesions, or ulcerations
Oral Mucosa: Pink, well hydrated. No masses/lesions noted. No leukoplakia.
Palate: Pink, well hydrated. No visible lesions/masses/scars.
Teeth: No dental caries, missing, or loose teeth. All teeth have appropriate shape.
Gingivae: No hypertrophy or recession. Unremarkable
Tongue: pink, well papillated. Frenulum intact. No masses/lesions/deviation.
Oropharynx: Well hydrated, no exudate/masses/lesions/foreign bodies noted. Grade 1 tonsils. Uvula pink, midline with no lesions or edema.
Neck: Trachea midline. No masses/lesions/pulsations noted. Neck supple, non-tender to palpation. Free range of motion. No stridor noted. No cervical adenopathy. No carotid pulses/thrills/bruits heard on auscultation. Thyroid is non-palpable, unremarkable. No goiter
Lymph nodes: Non-palpable, unremarkable preauricular, postauricular, submandibular, posterior cervical chain, anterior cervical chain, supraclavicular, and infraclavicular lymph nodes
Cardiovascular: JVP is 3.0cm above sternal angle with head of bed at 30 degrees. PMI located at the 5th ICS in midclavicular line. Carotid pulses are 2+ bilaterally without bruits. RRR. S1/S2 distinct with no murmurs or S3/S4 heard. No splitting of S2 or friction rubs appreciated.
Chest: Symmetrical with no deformities or trauma. Tenderness over the 5th ICS at the midclavicular line. Respirations unlabored, no paradoxical respirations or use of accessory muscles. Lat/AP diameter 2:1.
Lungs: Clear to auscultation and percussion bilaterally. Chest expansion/diaphragmatic excursion symmetrical. No adventitious sounds. Equal tactile fremitus throughout. Negative egophony test. Negative whispered pectoriloquy test. Negative bronchophony test.
Abdomen: Abdomen symmetric and flat. No scars, striae, or pulsations noted. Bowel sounds are normoactive in all 4 quadrants. No aortic/renal/iliac/femoral bruits heard. Non-tender to palpation and tympanic throughout. No guarding or rebound tenderness. No hepatosplenomegaly to palpation. No CVA tenderness appreciated.
Skin: Warm and moist. Good turgor. Non-icteric. No xerosis. No moles. No masses/lesions/deformities/scars
Hair: Average quantity and distribution. No seborrhea/lice/dandruff noted
Nails: No clubbing, capillary refill < 2 seconds in upper & lower extremities, appropriate shape & color.
Musculoskeletal: Tenderness over the posterior cervical spine. Appropriate alignment of spine. Full ROM. No joint erythema or tenderness. Appropriate muscular development. Normal gait
Neurological: CN 2-7 intact. Strength & sensation symmetric & intact. Reflexes 2+ throughout. Cerebellar testing WNL
Psychiatric: Oriented to person, place, & time. Good judgement/reason w/o abnormal affect, hallucinations, or abnormal behavior
RECTAL: Good sphincter tone with no anal, perineal or rectal lesions.
GENITALIA: Genital exam revealed appropriate developed female genitalia. No masses, hernias or inguinal lymphadenopathy. No perineal or perianal abnormalities are seen. No genital lesions or abnormal discharge.