Identification
Full name: J.T.
DOB: 2/1/1971
Date & Time: 9/6/2022 9:55AM
Location: NYPQH
Religion: “Not Religious”
Source Of Information: Translation from friend: Tenzin Language: Cantonese
Reliability: Reliable
Mode of Transport: Self
CC: “I am having surgery tomorrow”
History of Present Illness
51 y/o M with PMH of hypertension, allergies to pollen and cats, presents for presurgical physical. Pt is scheduled for septoplasty 9/7/2022. Pt c/o malodorous smell, nasal congestion, sinus pressure and green/yellow discharge in left nostril for 1 year. When exposed to allergens, pt experiences a runny nose and itchy eyes. Pt uses flonase once a day and notes “some” relief. Pt denies difficulty breathing, pain in sinus or nasal area, fever, cough or unexplained weight loss.
Past Medical History
Hypertension – 2 years Seasonal Allergies – 25 years
Immunizations
Influenza– 1 year ago
COVID – Pt received Pfizer booster “Spring 2021” Pneumonia – Pt has not received pneumonia vaccine
Past Surgical History
Pt denies any past surgeries
Medications
Amlodipine, QD, 5mg -Hypertension. Last dose: this morning Flonase, QD, 1 spray each nostril –allergies. Last dose: this morning
Allergies
Pollen – Runny nose, itchy eyes Cats – Runny nose, Itchy eyes
Family History
Both parents deceased. Cause of death unknown
Social history
1 beer 2-3 times per week Pt drinks coffee once a day Denies tobacco use
Denies recent travel Denies illicit drug use
Diet: “Home cooked meals, consisting of noodles”
Pt is single
Pt notes normal sleep patterns but feels discomfort when sleeping on left side due to sinus pressure
Pt denies exercise
Pt is an uber driver
Review of Systems
General: Denies recent weight loss or gain, loss of appetite, generalized weakness/fatigue, fever, chills, or night sweats
Skin, Hair, nails: Pt denies change in texture, excessive dryness or sweating, discolorations, pigmentations, moles/rashes, pruritus, changes in hair distribution
Head: denies headache, vertigo, head trauma, LOC
Eyes: denies visual disturbance, blurring, diplopia, fatigue with use of eyes, scotoma, halos,
lacrimation, photophobia, priuitis, last eye exam 1 year ago, pt does not wear glasses. Ears – denies deafness, pain, discharge, tinnitus, or hearing aids
Nose/Sinus: – See HPI
Mouth and throat: denies bleeding gums, sore tongue, sore throat, mouth ulcers, voice changes, dentures. Pt notes good dental hygiene.
Neck: denies localized swelling/lumps, stiffness/decreased range of motion
Pulmonary system: denies Dyspnea or dyspnea on exertion, cough, wheezing, hemoptysis,
cyanosis, orthopnea, paroxysmal nocturnal dyspnea
Cardiovascular System: HTN x 2 years, pt denies chest pain , palpitations, irregular heartbeat, edema/swelling of ankles or feet, syncope or known heart murmur
Genitourinary System: pt denies frequency, nocturia, urgency, oliguria, polyuria, dysuria, color of urine: yellow, Denies incontinence, awakening at night to urinate or flank pain
Pt notes he is not sexually active Pt denies impotence/anorgasmia Pt denies any past or present STI’s
Nervous System: pt denies seizures, headache, LOC, sensory disturbances, ataxia, loss of strength, change in cognition/ mental status/memory, weakness.
Musculoskeletal system: denies muscle/joint pain, deformity or swelling, redness.
Peripheral Vascular System: Denies Intermittent claudication, coldness or tropic changes,
varicose veins, peripheral edema, or color change.
Hematologic system: denies anemia, easy bruising or bleeding, lymph node enlargement, blood transfusions, hx of DVT/pe
Endocrine System: denies polyuria, heat or cold intolerance, goiter, excessive sweating, hirtruism Psychiatric System – pt denies depression/sadness, anxiety, obsessive/compulsive disorder. Pt
has never seen a mental health professional and is not taking psychiatric medications.
Physical Examination
Vitals Signs
Supine: (
121/76)
BP: Right arm- Seated: 128/82. Left arm – Seated: 127/86.
HR: 80
RR:18
SpO2: 98% on room air Temp: 98.7
Height: 70 inches Weight: 161 pounds BMI: 23.1
General: Pt appears in no acute distress. Alert and oriented x 3, Appears stated weight and age, neatly groomed
Head and Hair: The head is normocephalic and atraumatic without tenderness, visible or palpable masses, depressions, or scarring. Hair is of normal texture and evenly distributed.
Skin: Skin is warm, dry, and intact without rashes or lesions. Appropriate color for ethnicity.
Eyes: Symmetrical OU, no strabismus, no exophthalmos, sclera is white, cornea clear, and conjunctiva is pink.
Visual Acuity: 20/20 OS, 20/20 OD, 20/20 OU on Snellen chart – non corrected
Visual field: PERRL, EOM
Fundoscopy: Red reflex intact OU. Cup to disk ratio< 0.5 OU. No AV nicking, hemorrhages, or exudates
Ears: – Symmetrical and appropriate in size. No lesions/masses / trauma on external ears.
No discharge / foreign bodies in external auditory canals AU.
TM’s pearly white / intact with light reflex in at 7 o clock position on right, and 5 o clock position on left
Auditory acuity intact to whispered voice AU. Weber midline / Rinne reveals AC>BC AU.
Nose: Nasal bridge slightly deviated to the left. Septum deviated to the left on rhinoscopy. No masses / lesions / trauma /discharge. Nasal mucosa pink & well hydrated. No discharge noted on anterior rhinoscopy. No foreign bodies.
Sinuses – Slight puffiness palpated on left maxillary sinus. Non tender to palpation and percussion over bilateral frontal, ethmoid and maxillary sinuses.
Supine: (
124/72)
Lips – Pink, moist; no cyanosis or lesions. Non-tender to palpation.
Mucosa – Pink; well hydrated. No masses: lesions noted. Non-tender to palpation. No leukoplakia.
Palate – Pink; well hydrated. Palate intact with no lesions; masses; or scars. Non-tender to Palpation; continuity intact
Teeth – Good dentition / no obvious dental caries noted.
Gingivae – Pink; moist. No hyperplasia; masses; lesions; erythema or discharge. Non-tender to
palpation.
Tongue – Pink; well papillated; no masses, lesions or deviation. Non-tender to palpation.
Neck – Trachea midline. No masses; lesions; scars; 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.
Chest – Symmetrical, no deformities, no trauma. Respirations unlabored / no Paradoxical respirations or use of accessory muscles noted. Lat to AP diameter 2:1. Non-tender to palpation throughout.
Lungs – B/L lungs clear to auscultation. Chest expansion and diaphragmatic excursion symmetrical. Tactile fremitus symmetric throughout.
Abdomen – flat and symmetric with no scars, striae or pulsations noted. Bowel sounds normoactive in all four quadrants with no aortic/renal/iliac or femoral bruits. Non-tender to palpation and tympanic throughout, no guarding or rebound noted. Tympanic throughout, no hepatosplenomegaly to palpation, no CVA tenderness appreciated
Genitalia and Hernias: –
Anus, Rectum, and Prostate – .
Circumcised male. No penile discharge or lesions. No scrotal
swelling or discoloration. Testes Descended bilaterally, smooth and without masses.
Epididymis nontender. No inguinal or femoral hernias noted.
No perirectal lesions or fissures. External sphincter tone
intact. Rectal vault without masses. Prostate smooth and non-tender with palpable
median sulcus
Assessment:
51 y/o male with PMH of HTN, allergies to cats/pollen scheduled for septoplasty tomorrow presents for presurgical physical.
Differential Diagnosis and plan:
- Deviated Septum – Nasal examination shows nasal bridge deviated to the left. Intranasal examination shows septum deviated to the left, slight obstruction of the left nostril. Plan: Tx with allergy medications such as antihistamines, decongestants, nasal antihistamine sprays to decrease swelling of lining of septum and surrounding tissue. If deviated septum is causing nasal obstruction, pt is a candidate for septoplasty.
- Nasal Polyp – Pt’s with seasonal allergies can be predisposed to nasal polyps.
Plan: Confirm with nasal speculum or rhinoscope. Tx with intranasal glucocorticoids. If no relief, use oral glucocorticoids - Nasal Foreign Body – Turbinate not completely visible on physical examination. Pt also notes bad odor which could be due to growth of bacteria from a foreign body.
Plan: Consider Afrin spray or lidocaine with epi prior to removal. Keep the patient upright to avoid foreign body going back into the airway. If necessary, use the “parent Kiss” technique. (Place hand over pt’s mouth, perform short sharp blow of air into pt’s nostril to expel foreign body) - Chronic Sinusitis – pt experiences congestion of nose for more than 12 weeks.
Plan: Tx with analgesia, mechanical irrigation with buffered hypertonic saline, OTC decongestants, Intranasal decongestants, intranasal corticosteroids. If suspected bacterial infection, Augmentin for 7-10 days, 2nd line are fluoroquinolones or doxycycline. - Toxic Inhalation – frequent malodorous smell. Pt is an Uber driver and could have Been exposed to toxins brought in by a client.
Plan: Evaluate pt with labs such as BMP, LFT, CBC, CPK, EKG, and Thyroid Function tests. Tx includes decontamination such as irrigation for dermal exposure as well as activated charcoal or oral gastric lavage.
