Identification
Full Name : S. K.
Date & Time: 5/10/2022– 11:04 AM
Location: NYPQ
Religion: Catholic
Source of Information: Self
Reliability: Reliable
Mode of Transport: Driven by friend
CC: “I have right calf pain” x 14 days
History of Present Illness
72 y/o male with PMH of hypercholesterolemia, hypertension, hypothyroid and BPH presented with “shocking” 6/10 right calf pain that radiates to the right hip for 14 days. Pt notes the pain worsens with any movement and the pain has worsened in the last 3 days. Pt had an MRI on 5/3: herniated disk, protrusion of L5-S1. Pt notes the right calf pain and right hip pain is alleviated when taking flexeril and robaxin, which is administered at the hospital. Pt denies trauma, hx of falls, redness or arthritis.
PMH
Hypercholesterolemia x 25 years
Hypertension x 25 years
Hypothyroid x 20 years
BPH x 5 years
Immunizations: up to date
Last influenza shot: 2021
Covid booster:Pfizer – 5 months ago
Past surgical history
Appendectomy x 5 years ago, no complications or blood transfusions, New York, pt cannot recall which hospital.
Tonsillectomy x over 20 years ago, no complications or blood transfusions. Pt does not remember which hospital.
Medications
Robaxin, 500mg, QID, last dose this morning – back pain
Flexeril, 5mg, TID PRN, last dose this morning – back pain
Lipitor, 20mg, QD, last dose this morning – High cholesterol
Finasteride 5mg, QD, last dose this morning – BPH
Levothyroxine, 25mcg, QD, last dose this morning – Hypothyroidism
Metoprolol, 25mg, QD, last dose this morning – Hypertension
Allergies
Pt denies drug, environmental, animal, and food allergies.
Family history
Pt was adopted
Grandfather – decreased, cause and age of death: unknown
Grandmother – deceased, cause and age death: unknown
Mother – deceased, cause and age of death unknown
Father – deceased, cause and age of death unknown
Denies family hx of cancer, diabetes, cardiovascular disease
Social history
Pt states he has never drank alcohol
Pt denies tobacco use
Pt denies illicit drug use
Pt denies recent travel
Pt is single
Pt is currently retired for 7 years – Security Guard
Pt notes his diet is well-balanced consisting of fruits, vegetables
Pt denies recent change in sleep habits. Pt notes 7-8 hours of sleep each night
Pt is not normally physically active
Pt wears a seatbelt
Review of Systems
General: Denies recent weight loss or gain, loss of appetite, generalized weakness/fatigue, fever, chills, night sweats
Skin, Hair, nails: 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 the use of eyes, scotoma, halos, lacrimation, photophobia, and pruitis. Pt does not wear glasses
Ears: denies deafness, pain, discharge, tinnitus, hearing aids
Nose/Sinuses: denies Discharge, epistaxis, obstruction
Mouth and throat: denies bleeding gums, sore tongue, sore throat, mouth ulcers, voice changes, dentures. Last dental exam: 1 year ago
Neck: Denies localized swelling/lumps, stiffness/decreased range of motion
Breasts: denies lumps, nipple discharge, pain.
Pulmonary System: Denies dyspnea, dyspnea on exertion, cough, wheezing, hemoptysis, cyanosis, orthopnea, or paroxysmal nocturnal dyspnea (PND).
Cardiovascular System: Hx of HTN x 25 years, denies chest pain,, palpitations, irregular heartbeat, edema/swelling of ankles or feet, syncope, known heart murmur
Gastrointestinal System: denies change in appetite, intolerance to specific foods, N/V/D, dysphagia, pyrosis, flatulence, eructations, abdominal pain, diarrhea, jaundice, change in bowel habits, hemorrhoids, constipation, rectal bleeding, blood in stool.
Genitourinary System: denies frequency, nocturia, urgency, oliguria, polyuria, dysuria, color of urine: yellow, Denies incontinence, flank pain, denies impotence/anorgasmia, any past or present STIs. Pt has not been sexually active for the last 3 years. Last prostate exam: 1 year ago – “Normal”
Genitourinary System: denies frequency, nocturia, urgency, oliguria, polyuria, dysuria, color of urine : yellow, Denies incontinence, awakening at night to urinate or flank pain
Nervous: denies seizures, headache, LOC, sensory disturbances, ataxia, loss of strength, change in cognition/ mental status/memory, weakness.
Musculoskeletal system: See HPI
Peripheral Vascular System: denies Intermittent claudication, coldness or tropic changes, varicose veins, peripheral edema, 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, hirsutism or goiter
Psychiatric: Denies depression/sadness, anxiety, OCD or ever seeing a mental health professional.
Vitals Signs
BP: Right arm- Seated: 132/90. Supine: 121/76, (pt declined Supine – BP due to pain)
Left arm – Seated: 134/86. Supine: 124/72, (pt declined Supine – BP due to pain)
HR: 90
RR:18
SpO2: 98% on room air
Temp: 98.3
Height: 66 inches
Weight: 132
BMI: 21
Physical
General: Pt appears to be in slight distress holding his right upper leg but able to speak and breath well. Appears stated weight and age, neatly groomed,
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.
Nail: Nail Beds pink with no cyanosis or clubbing.
Eyes: Symmetrical OU, no strabismus, no exophthalmos, sclera is white, cornea clear, and conjunctiva is pink.
Visual Acuity corrected: 20/20 OS, 20/20 OD, 20/20 OU on Snellen chart
Visual field: PERRL, EOM
Fundoscopy: Red reflex intact OU. Cup to disk ratio< 0.5 OU. No AV nicking, hemorrhages, or exudates
Ears: No cerumen visualized b/l. Symmetrical, no lesions, no masses, no trauma. No discharge. TM’s are pearly white. Cone of light at “5 o clock” position in the right ear, and “7 o clock” position in left ear
Auditory test:
– Auditory acuity intact on whisper test
– Weber is midline
– Rinne AC>BC b/l
Nose: – Symmetrical / no masses / lesions / deformities / trauma / discharge. Nares patent bilaterally / Nasal mucosa pink & well hydrated. No discharge noted on anterior rhinoscopy. Septum midline without lesions / deformities / injection / perforation. No foreign bodies.
Sinuses – Non tender to palpation and percussion over bilateral frontal, ethmoid and maxillary sinuses.
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.
Oropharynx – Well-hydrated; no injection; exudate; masses; lesions; foreign bodies.
Tonsils – Tonsils not present due to tonsillectomy. Uvula pink, no edema, lesions
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: Clear to auscultation and percussion bilaterally. Chest expansion and diaphragmatic excursion symmetrical. Tactile fremitus symmetric throughout. No adventitious sounds.
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
