H&P 1

Identifying data: 

Name: MR

Sex: Male

Age: 42

Date and time: 4/12/2021 10:00AM 

Location: StatCare Urgent Care Astoria, Queens

Source of information, self, reliable 

Chief complaint: Right lower leg pain X 4 days

MR is a 42M with no PMH presents to urgent care with complaint of right lower leg pain since Friday 4/9. The pain started as a slight discomfort while he was sitting, and progressed to severe dull constant pain 7/10. It is located on the lateral right leg below the knee, and is non radiating. Patient states he has full range of motion of the extremity. Sitting and resting makes the pain worse, but standing and walking improves it. He took Advil and Aspirin without relief. The patient denied anything similar happening in the past. He admits to nausea and loss of appetite. He denies trauma, swelling or redness of the leg, vomiting, fever, cough, SOB, abdominal pain, headache, dizziness, weight loss, night sweats, recent travel, recent surgery. The patient states he came in today because the pain was getting worse and preventing him from working. 

Past medical history: 

Denies past medical history 

Hospitalizations: 

Denies hospitalizations other than surgeries (see below)

Immunizations: 

Patient is up to date on immunizations 

Past surgical history: 

 Appendectomy X5 years ago

Hernia repair X 5 years ago

Left femur, remote 

Unknown dental surgery, remote 

Patient denied complications or need for transfusions. 

Medications: 

Patient denied taking any daily medications 

Allergies: 

Patient denied allergies to medication, food and environment 

Family history: 

Mother: alive and well

Father: Diabetes, alive. 

Patient denied knowing grandparents family history. Denied family history of cardiac disease, thyroid disease, kidney disease, allergies, ung disease, GI disease, urinary tract diseases, psychiatric disorders, nervous disorders, metabolic disorders, and other endocrine disorders.

Social history:

Patient lives alone and works as a field engineer. He denies smoking and use of recreational drugs. Patient drinks a six pack of beer every few weekends. 

Review of systems:

General: admits to nausea and loss of appetite, denied general weakness, fever, chills, vomiting, fatigue, diaphoresis, night sweats and changes in weight

Head: denied trauma , headache, confusion, lightheadedness, changes in vision, loss of consciousness 

Neurologic: denied slurred speech, neck stiffness, decreased sensation, numbness, tingling, syncope 

Eyes: denied blurred vision, discharge. Does not wear corrective lenses

ENT: denied vertigo, rhinorrhea, stuffiness, sneezing, sore throat, swollen lymph nodes, tinnitus, neck pain

Cardiac: patient denied leg edema, claudication, known heart murmurs, chest pain, shortness of breath, palpitations 

Pulmonary: patient denied cough, shortness of breath, pain with inspiration, wheezing, hemoptysis 

Hematology: patient denied bruising, anemia 

Skin: patient denied rash, sores, itching 

GI: patient denied bowel changes, abdominal pain, diarrhea, constipation, dysphagia

GU: patient denied urgency, dysuria, polyuria, hematuria, nocturia, incontinence

MSK: admits to right lower leg pain, patient denied joint pain and swelling 

Psychiatric: patient denied anxiety, depression, mood changes. 

Physical exam: 

Vitals: 97.9 T orally, HR 64 regular, BP 142/90 standing, height 5 ft 6inch, weight 180 pounds, BMI 29.5. RR 16 unlabored, O2 sat 97% on room air. 

General:42 male, alert and orientedX3, pacing, appears stated age. 

Head: normocephalic and atraumatic

Eyes: pupils equal round and reactive to light, non icteric no conjunctival injection. Upper and lower eyelids are normal.

ENT: mucus membranes moist, no erythema or exudate in the back of the throat, no lymphadenopathy. Trachea midline, thyroid not-enlarged. Uvula midline. 

Cardiac: regular rate and rhythm, S1 and S2 auscultated. no murmurs, rubs or gallops. Radial pulses 2+ bilaterally, capillary refill < 2 seconds bilaterally. No leg edema. 

Pulmonary: lungs clear to auscultation bilaterally, no wheezes, rales or rhonchi, tachypnea. Normal respiratory effort no retractions. 

Abdominal: bowel sounds present in all four quadrants, abdomen soft and non tender, with no distention, no hepatosplenomegaly. 

Skin: no rashes, bruises or scars. No pallor noted. 

Extremity: full range of motion, strength grossly intact in upper and lower extremity. No unilateral calf swelling or tenderness. No clubbing, cyanosis or edema. No palpable lesion and non tender to palpation on exam. Negative Homan’s sign. DP pulses 2+ bilaterally. 

Differential diagnosis: 

1. Sarcoma 
2. DVT 
3. Muscle strain 
4. Claudication 
5. Cellulitis  

Plan: 

1. Pain control with Naproxen 500mg every 12 hours for 7 days 
2. X-ray right leg tibia/fibula 
3. Hold doppler US since no risk factors for DVT, no calf tenderness or swelling, no cellulitis. 

H&P 2

Identifying data: 

Name: CG 

Sex: Male

Age: 25

Date and time: 4/19/21 16:00

Location: Statcare Urgent Care Astoria, Queens

Source of information: self, reliable

Chief complaint: left eye swelling and crusting X1 day

HPI: 

25M with no PMH presents to urgent care with complaint of red and swollen left eye for the past day. He states he was hit in his left eye by a tree branch 3 days ago, he had pain that day which resolved, and then today woke up with a swollen, red, and crusted left upper eyelid. He complains of soreness. He denied eye pain or itchiness, changes in vision, photophobia, fever, headache, dizziness, nasal discharge, sore throat, ear pain. He does not wear glasses or contacts. This had never happened before and he came in today because he was worried about an infection. 

Past medical history: 

Denied past medical history 

Hospitalizations:

Denied hospitalizations 

Immunizations:

Up to date on immunizations

Past surgical history:

Denied past surgical history 

Medications: 

Patient denied taking daily medications

Allergies:

Patient denied allergies to medication, food and environment

Family history: 

Patient denied family history of cardiac disease, thyroid disease, kidney disease, allergies, lung disease, GI disease, urinary tract diseases, psychiatric disorders, nervous disorders, metabolic disorders, and endocrine disorders.

Review of systems:

General: patient denied nausea, anorexia, general weakness, fever, chills, vomiting, fatigue, diaphoresis, night sweats and changes in weight

Head: patient denied trauma , headache, confusion, lightheadedness, changes in vision, loss of consciousness 

Neurologic: patient denied slurred speech, neck stiffness, decreased sensation, numbness, tingling, syncope 

Eyes: admits to crusted discharge and eye swelling, denied blurred vision, itching, photophobia. Does not wear corrective lenses

ENT: patient denied vertigo, rhinorrhea, stuffiness, sneezing, sore throat, swollen lymph nodes, tinnitus, neck pain

Cardiac: patient denied leg edema, claudication, known heart murmurs, chest pain, shortness of breath, palpitations 

Pulmonary: patient denied cough, shortness of breath, pain with inspiration, wheezing, hemoptysis 

Hematology: patient denied bruising, anemia 

Skin: patient denied rash, sores, itching 

GI: patient denied bowel changes, abdominal pain, diarrhea, constipation, dysphagia

GU: patient denied urgency, dysuria, polyuria, hematuria, nocturia, incontinence

MSK: patient denied joint pain and swelling 

Psychiatric: patient denied anxiety, depression, mood changes. 

Physical exam: 

Vitals: 98.8T orally, HR 70 regular, BP 126/76, height 6 feet, weight 156 pounds, BMI 21.2. RR 16 unlabored, O2 sat 99% on room air. 

General: 25 male, alert and orientedX3, no acute distress, appears stated age. 

Head: normocephalic and atraumatic

Eyes: left upper eyelid with mild edema and erythema, minimally injected left conjunctiva, EOMIs no visible discharge, sclera non-icteric, pupils equal, round and reactive to light, lower eyelid normal. Right eye unremarkable with  pupils equal round and reactive to light, non icteric sclera, no conjunctival injections. Visual fields full by confrontation bilaterally.

ENT: mucus membranes moist, no erythema or exudate in the back of the throat, no lymphadenopathy. Trachea midline, thyroid not-enlarged. Uvula midline. 

Cardiac: regular rate and rhythm, S1 and S2 auscultated. no murmurs, rubs or gallops. Radial pulses 2+ bilaterally, capillary refill < 2 seconds bilaterally. No leg edema. 

Pulmonary: lungs clear to auscultation bilaterally, no wheezes, rales or rhonchi, tachypnea. Normal respiratory effort no retractions. 

Abdominal: bowel sounds present in all four quadrants, abdomen soft and non tender, with no distention, no hepatosplenomegaly. 

Skin: no rashes, bruises or scars. No pallor noted. 

Extremity: full range of motion, strength grossly intact in upper and lower extremity. No unilateral calf swelling or tenderness. No clubbing, cyanosis or edema. DP pulses 2+ bilaterally. 

Differential diagnosis:

1. Preseptal cellulitis 
2. Blepharitis 
3. Conjunctivitis 
4. Corneal abrasion 

Assessment: 

25M with no PMH presents with complaint of left upper eyelid redness and swelling. Denied vision changes, headache. Physical exam reveals left upper eyelid swollen, erythematous, no discharge visualized. EOMIs intact, visual fields full by confrontation. Left conjunctival injection. Presentation and physical exam consistent with blepharitis and conjunctivitis 

Plan: 

1. Treat with Ofloxacin eye drop 0.3%  and erythromycin ointment 0.5% for 7 days 
2. Discharge with follow up if it does not improve or symptoms worsen in the next three days