HISTORY:

Identifying data:

Date & Time: April 26, 2022 10:00am

Full name: Mrs. F.R

Address: Flushing, NY

Date of birth: March 17, 1937

Location: NYHQ, Flushing, NY

Religion: Catholic

Marital status: Widowed

Source of information: Self

Reliability: Reliable

Source of referral: PCP

Mode of transport: Granddaughter

 

Chief Complaint:

“I had pain in my stomach” x 2 weeks

History of Present Illness:

85 y/o female with no significant PMH presented to the ED w/ RUQ pain 8 days ago. Pt states the pain began about 2 weeks ago and would come and go. Describes the pain as a sharp pain that would come and go with a 10/10 severity. Pt also had a fever of 101.2. Pain worsened with inhalation and with movement and was alleviated by sitting still. Pt states pain would radiate across the RUQ towards the back. Denies nausea, vomiting, change in bowel habits, chills. Pt had a cholecystectomy performed. States her pain has improved since then but has the pain if she lays on her right side. After her surgery, pt has developed a hoarse voice that has not been improving. Pt reports dysphagia, especially when swallowing solid foods. She states she “feels like something is stuck in my throat on the right side.” She has been spitting up clear phlegm. Pt had no intubations prior to cholecystectomy or prior ENT visits. Denies odynophagia, cough, regurgitation.

 

Past Medical History:

• No past medical history.
• Immunizations: up to date; flu vaccine yearly (unknown date); Covid vaccines and booster up to date (unknown dates).
• Past Hospitalization: None

Past Surgical History:

• Laparoscopic Cholecystectomy – age 85, NYPQ, Flushing, NY. Due to cholecystitis, no complications.
• Denies past injuries or blood transfusions.

Medications:

• Vitamin B12 1000 mcg, 1 tab PO daily, for OTC use, last dose 9 days ago
• Denies use of herbal supplements.

Allergies:

• NKDA, no food or environmental allergies.

Family History:

• Mother – Deceased at age 92, from renal failure.
• Father – Deceased at unknown age, unknown reason.
• Maternal/paternal grandparents – Decreased at unknown age & unknown reasons
• Daughter – Age 50, alive and well.
• Son – Age 53, alive and well.

Social History:

• Habits – Admits to caffeine use, 1 cup of coffee in morning. Non smoker, denies alcohol use.
• Travel – No recent travel
• Marital history – Widowed, husband deceased at 86 (1 year ago) from COVID-19.
• Occupational history – Retired Board of Ed worker
• Home situation – Lives alone in 1 bedroom apartment.
• Diet – Admits to balanced diet consisting of protein, grains, vegetables. States typical meal of chicken, broccoli, pasta
• Sleep patterns – Admits to good sleep pattern
• Exercise – Admits to mild exercise consisting of walking a few blocks each day to buy a newspaper.
• Safety measures – Admits to seat belt use.

 

Review of Systems:

• General: Denies generalized weakness/fatigue, fever, chills, night sweats, weight loss of gain, changes in appetite.
• Skin, hair, nails: Denies changes in texture, excessive dryness or sweating, discolorations, pigmentations, moles/rashes, pruritus, changes in hair distribution.
• Head: Denies headaches, vertigo, head trauma.
• Eyes: Admits to glasses use for reading. Last eye exam 5 months ago. Unknown visual acuity. Denies lacrimation, pruritus, visual disturbances, photophobia.
• Ears: Denies deafness, pain, discharge, tinnitus, hearing aid use.
• Nose: Denies discharge, obstruction, epistaxis.
• Mouth/throat: Admits to voice changes, to dentures use. Last dental exam about 3 months ago. Denies bleeding gums, sore tongue, sore throat, mouth ulcers.
• Neck: Denies localized swelling/lumps, stiffness/decreased ROM.
• Breast: Last mammogram 6 years ago, normal. Denies lumps, nipple discharge, pain.
• Pulmonary: Admits to excess phlegm production. Denies dyspnea, dyspnea on exertion, orthopnea, paroxysmal nocturnal dyspnea, cough, wheezing, cyanosis.
• Cardiovascular: Denies chest pain, palpitations, hx of HTN, irregular heartbeat, edema/swelling of ankles or feet, syncope, known heart murmur.
• Gastrointestinal: Admits to dysphagia, abdominal pain. Admits to normal bowel movements 1 time per day. Last colonoscopy exam 9 years ago, normal. Denies changes in bowel movements, intolerance to specific foods, change in appetite, pyrosis, unusual flatulence or eructation, diarrhea, jaundice, hemorrhoids, constipation, rectal bleeding, blood in stool, nausea, vomiting.
• Genitourinary: Denies urinary frequency, urinary urgency, nocturia, oliguria, polyuria, dysuria, incontinence, flank pain.
• Menstrual/Obstetrical: G2, P(T2 P0 A0 L2), menarche age 13, LMP age 54. Denies hot flashes/associated menopause symptoms, breakthrough bleeding, vaginal discharge.
• Sexual History: Denies being sexually active in over 20 years, impotence, history of STIs, contraception use.
• Musculoskeletal: Denies arthritis, muscle pain, deformity or swelling, redness.
• Nervous system: Denies seizures, headache, loss of consciousness, sensory disturbances, ataxia, loss of strength, change in cognition/mental status/memory.
• Peripheral vascular: Denies intermittent claudication, varicose veins, coldness or trophic changes, peripheral edema or color changes.
• Hematologic: Denies anemia, easy bruising or bleeding, lymph node enlargement, blood transfusions, history of DVT/PE.
• Endocrine: Denies polyuria, polydipsia, polyphagia, heat or cold intolerance, excessive sweating, goiter, hirsutism.
• Psychiatric:  Denies depression/sadness, anxiety, OCD, or ever seeing a mental health professional.

 

PHYSICAL:

General: Slender female, neatly groomed, appears younger than her stated age of 82.

Vital Signs:

BP:                  R                                 L

Seated             124/82                         126/84

Supine             123/82                         125/82

R: 16/min, unlabored                          P: 65 beats/min, regular

T: 98.8 degrees F (oral)                      O2 Sat: 99% Room air

Height: 64       Weight: 145 lbs          BMI: 24.9

Skin: Poor turgor. Warm & moist. Nonicteric, no lesions noted, no scars, no tattoos.

Hair: Short, grey hair to ears. Reduced quantity and distribution.

Nails: No clubbing, capillary refill < 2 seconds in upper and lower extremities.

Head: Normocephalic, atraumatic, non-tender to palpation throughout.

Ears: Symmetrical and appropriate in size. No lesions, masses or trauma on external ears. No discharge or foreign bodies on external auditory canals AU. TM pearly grey and intact with light reflect in good position AU. Auditory acuity intact to whispered voice AU. Weber midline. Rinne reveals AC > BC AU.

Nose: Symmetrical. No masses, lesions, deformities, trauma or discharge. Nares patent bilaterally, nasal mucosa pink & well hydrated. No discharge noted on anterior rhinoscopy. Septum midline without lesions, deformities, injection or perforation. No foreign bodies.

Sinuses: Non tender to palpation and percussion over bilateral frontal, ethmoid and maxillary sinuses.

Mouth/Pharynx-

Lips: Pink, moist, no cyanosis or lesions.

Mucosa: Pink, well hydrated. No masses or lesions noted. No leukoplakia.

Palate: Pink, well hydrated. Palate intact with no lesions, masses, scars.

Teeth: Dentures in place, no missing teeth.

Gingivae: Pink, moist. No hyperplasia, masses, lesions, erythema, or discharge

Tongue: Pink, well hydrated. No masses, lesions or deviation.

Oropharynx: Well hydrated. No injection, exudates, masses, lesions or foreign bodies. Tonsils grade 2 present with no injection or exudate. Uvula pink, no edema or lesions.

Neck: Trachea midline. No masses, lesions, scars, or pulsations noted. Supple; non-tender to

palpation. FROM; no stridor noted. 2+ Carotid pulses, no thrills; bruits noted bilaterally, no cervical adenopathy noted.

Thyroid: Non-tender; no palpable masses; no thyromegaly; no bruits noted.

Eyes: Symmetrical OU. No strabismus, exophthalmos or ptosis.  Sclera white, cornea clear, conjunctiva pink.
Visual acuity uncorrected – 20/25 OS, 20/25 OD, 20/30 OU
Visual fields full OU. PERRL. EOMs intact with no nystagmus
Fundoscopy – Red reflex intact OU. Cup to disk ratio< 0.5 OU. No AV nicking, hemorrhages, exudates or neovascularization OU.

Cardiac: JVP is 2 cm above the sternal angle with the head of the bed at 30°. PMI in 5^th ICS 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 appreciated.

Chest: Symmetrical, no deformities, no trauma.  Respirations unlabored / no paradoxic respirations or use of accessory muscles noted. Lat to AP diameter 2:1. Non-tender to palpation throughout.

Lungs: Clear to auscultation and percussion bilaterally. Chest expansion and diaphragmatic excursion symmetrical. Tactile fremitus symmetric throughout. No adventitious sounds.

Abdomen: Three Laparoscopic cholecystectomy incision scars noted on RUQ. RUQ tenderness to palpation with guarding. Abdomen flat and symmetric, striae or pulsations noted.  Bowel sounds normoactive in all four quadrants with no aortic/renal/iliac or femoral bruits. No rebound tenderness noted. Tympanic throughout, no hepatosplenomegaly to palpation, no CVA tenderness appreciated.