H&P 3

HISTORY:  

Identifying data:

Date & Time: March 1, 2022 9:00am

Full name: Mrs. B

Address: Flushing, NY

Date of birth: July 5, 1946

Location: NYHQ, Flushing, NY

Religion: Christian

Marital status: Widowed

Source of information: Self

Reliability: Reliable

Source of referral: Self; PCP unable to recall

Mode of transport: Self

 

Chief Complaint:

“Chest pain” x 3 hours

History of Present Illness:

75 year old female with PMH of emphysema and GERD, who presented to the ED 1 day ago with left sided chest pain x 3 hours. She states she was woken out of her sleep at 3am to the pain abruptly starting. The pain was constant and sharp, described as a “knife going into my chest” with a chest tightness sensation, lasting the next 4 hours. Described pain as a 7 out of 10 in severity. Symptoms worsened with quick movements and with inspiration. Patient did not take any medications or treatments at home and arrived to the ED approximately 2 hours after pain onset, where she was administered nitroglycerin and aspirin, which provided symptom relief. Patient has also been experiencing fatigue since symptom onset. States she has not experienced something similar in the past. Symptoms today have improved and patient is currently not feeling any pain. She is currently awaiting imaging. She denies recent trauma, person hx of MI, family hx of MI, strenuous activity the days prior, recent spicy meal, or taking new medications. Denies SOB, palpitations, dyspnea, dyspnea on exertion, cough, headache, lightheadedness, nausea, vomiting, or sweating.

 

Past Medical History:

  • Hypercholesterolemia x 8 years, well controlled on medications
  • Rheumatoid arthritis x 14 years, well controlled on medications
  • Emphysema x 3 years, well controlled on medications
  • GERD x 2 years, uncontrolled
  • Immunizations up to date; flu vaccine yearly (unknown date); Covid vaccines and booster up to date (unknown dates).

Past Surgical History:

  • Total RT hip replacement – age 66, Flushing Hospital, Flushing, NY. Due to arthritis, no complications
  • Hysterectomy – age 45, Flushing Hospital, Flushing, NY. Due to fibroids, no complications.
  • Double mastectomy – age 40, Flushing Hospital, Flushing, NY. Due to fibrocysts, no complications.
  • Denies past injuries or blood transfusions.

Medications:

  • Methotrexate (Otrexup) 25mg/0.4mL subq INJ once a week, for rheumatoid arthritis, last dose 2/23/22
  • Rosuvastatin (Crestor) 10mg, 1 tab PO daily, for hypercholesterolemia, last dose this morning
  • Incruse Ellipta 62.5mcg/actuation INH 1 pump daily, for emphysema, last dose this morning
  • Folic acid 20mg, 1 capsule PO daily, for general health, last dose 1 day ago
  • Vitamin D 125mcg, 1 tab PO daily, for general health, last dose 1 day ago
  • Denies use of herbal supplements.

Allergies:

  • NKDA, no food or environmental allergies.

Family History:

  • Mother – Deceased at age 76 from natural causes, hx of dementia & rheumatoid arthritis
  • Father – 97 alive and well, hx of BPH, hyperthyroidism
  • Maternal/paternal grandparents – Deceased at unknown age & unknown reasons
  • Daughter – Age 44, alive and well
  • Son – Age 47, alive and well

Social History:

  • Habits – Ex smoker of 30 years, ½ pack a day. Admits to occasionally drinking socially at parties 1-2 drinks. Denies caffeine use.
  • Travel – No recent travel
  • Marital history – Widowed, husband deceased at 69 (8 years ago) from pancreatic cancer
  • Occupational history – Retired USPS worker
  • Home situation – Living with her adult daughter and father.
  • Diet – Denies well balanced diet. States breakfast usually consists of grits and sausage. Dinner consists of chicken and sweet potato, occasionally eats broccoli.
  • Sleep patterns – Admits to varying sleep patterns. States most days she is up at night and sleeps during the day.
  • Exercise – Admits exercise consisting of light walking usually 6-7 blocks per day.
  • Safety measures – Admits to seat belt use.

 

Review of Systems:

  • General: Admits to generalized weakness/fatigue. Denies 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. Last eye exam 2020, 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 dentures use. Last dental exam December 2021. Denies bleeding gums, sore tongue, sore throat, mouth ulcers, voice changes.
  • Neck: Denies localized swelling/lumps, stiffness/decreased ROM
  • Breast: Last mammogram 2020, normal. Denies lumps, nipple discharge, pain.
  • Pulmonary: Denies dyspnea, dyspnea on exertion, orthopnea, paroxysmal nocturnal dyspnea, cough, wheezing, cyanosis.
  • Cardiovascular: Admits to chest pain x 6 hours. Denies palpitations, hx of HTN, irregular heartbeat, edema/swelling of ankles or feet, syncope, known heart murmur.
  • Gastrointestinal: Admits to normal bowel movements 1-2 times per day. Last colonoscopy exam October 2020, normal. Denies changes in bowel movements, change in appetite, intolerance to specific foods, nausea, vomiting, dysphagia, pyrosis, unusual flatulence or eructation, abdominal pain, diarrhea, jaundice, hemorrhoids, constipation, rectal bleeding, blood in stool.
  • Genitourinary: Denies urinary frequency, urinary urgency, nocturia, oliguria, polyuria, dysuria, incontinence, flank pain.
  • Menstrual/Obstetrical: G3, P(T2 P0 A1 L2), menarche age 13, LMP age 45 at time of hysterectomy. Denies hot flashes/associated menopause symptoms, breakthrough bleeding, vaginal discharge.
  • Sexual History: Denies being sexually active since 2014, impotence, history of STIs, contraception use.
  • Musculoskeletal: Admits to rheumatoid arthritis x 14 years. Denies 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, coldness or trophic changes, varicose veins, 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 75.

Vital Signs:    

BP:                  R                                 L

Seated             132/87                         136/83

R: 15/min, unlabored                          P: 88 beats/min, regular

T: 98.4 degrees F (oral)                      O2 Sat: 98% Room air

Height: 63       Weight: 115 lbs          BMI: 20.4

Skin: Warm & dry, good turgor. Nonicteric, no lesions noted, no scars, no tattoos.

Hair: Short, black hair to ears. Average quantity and distribution.

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

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