Identifying data

Date and Time: 6/01/21, 9:00 AM

Name: RJ

Age: 48

Sex: Male

Marital status: married

Race: Black

Address: Jamaica, Queens

Location: Amazing Medical Services, PC. Jamaica, Queens

Source of information: self, reliable

Chief complaint: “ right foot and right shoulder pain” since April 5 2021.

HPI: RJ is a 48-year-old male with 5 pack years,  presenting to primary care with complaint of right shoulder and right foot pain since April 5 2021. On April 5 2021 he had a motorcycle accident in which he had several fractures in his right shoulder and right foot. He had surgery where 5 screws were placed in his right shoulder, and 5 screws in his right foot. Since the accident he has been managing his pain with Naproxen and Tylenol, but he ran out of medication last week. He has been using a cane to walk and still has a limp. The pain is currently 7/10, constant, throbbing and non radiating. The pain is worse at night and with movement. Patient has a follow up appointment with an orthopedic specialty in five weeks. He came in today requesting a refill of his pain medication. He denies recent additional trauma, fever, redness or swelling surrounding the wounds.

Past medical history:

Denies past medical history

Immunizations: uptodate on vaccinations, received second dose of Moderna vaccine in 4/21

Past surgical history: April 5, 2021 orthopedic surgery due to motorcycle accident and multiple fractures in the right shoulder and right foot, 5 screws were placed in the right shoulder and right foot. Denies complications thus far.

Hospitalizations: motorcycle accident April 5, 2021.

Medications:

Tylenol 650 mg every 4-6 hours PRN for pain

Naproxen 500 mg every 12 hours PRN for pain

Allergies: denies allergies to medications, food or environment

Family history:

Grandparents: does not know

Mother: alive, HTN

Father: alive, HTN and DM

3 sons and one daughter: alive and well

Denies family history of thyroid disease, kidney disease, allergies, lung disease, GI disease, urinary tract disease, psychiatric disorder, nervous system disorder, cancer, metabolic disorders and other endocrine disorders

Social history:

Habits: drinks 1-5 beers every weekend. Smokes 5 cigarettes a day for the past 20 years (5 pack years). Denies recreational drug use.

Travel: denies recent travel

Marital status: married

Occupation: not currently working

Home: lives with wife and 4 children.

Diet: breakfast includes cereal or breakfast sandwich, lunch fast food, dinner fish/meat/chicken

Sleep: sleeps 6-8 hours a night

Exercise: currently not able to do more than a few steps due to injury

 Review of systems:

General: Denies recent fatigue, weight loss, gain, loss of appetite, weakness, fever, chills, night sweats

Skin, Hair, Nails: Denies changes to texture, hair distribution, excessive dryness or sweating, discolorations, pigmentations, moles, rashes, pruritus

Head: Denies headaches, vertigo, lightheadedness, head trauma

Eyes: Denies visual disturbances, blurry vision lacrimation, pruritus. Does not wear corrective lens

Ears: Denies deafness, pain, discharge, tinnitus, hearing aids

Nose/Sinus: Denies discharge, epistaxis, obstruction

Mouth and Throat: Denies bleeding gums, sore tongue, sore throat, mouth ulcers, voice changes.

Neck: Denies localized swelling/lumps, stiffness/decreased range of motion

Breast: Denies nipple discharge, lumps, pain.

Pulmonary: Denies cough, dyspnea, SOB, wheezing, hemoptysis, cyanosis, orthopnea, paroxysmal nocturnal dyspnea

Cardiovascular: Denies chest pain, hypertension, palpitations, irregular heartbeat, edema/swelling ankles, syncope, known heart murmur

Gastrointestinal System: Denies changes in appetite, intolerance to specific food, nausea and vomiting, dysphagia, pyrosis, flatulence, eructations, abdominal pain, diarrhea, constipation jaundice, change in bowel habits, hemorrhoids, rectal bleeding, melena, colonoscopy

Genitourinary System: Denies nocturia, urgency, polyuria, frequency, oliguria, dysuria, incontinence, pain in flank

Sexual: sexually active wife, one partner. Denies testing positive for any STI.

Nervous system: Denies seizures, headaches, loss of consciousness, sensory disturbances, ataxia, loss of strength, change in cognition, mental status, memory, weakness

Musculoskeletal system: Admits to right shoulder and right foot pain. Denies arthritis.

Peripheral vascular: Denies intermittent claudication, coldness, trophic changes, varicose veins, peripheral edema, color changes

Hematologic: Denies lymph node enlargement, anemia, easy bruising, blood transfusions, history of DVT/PE

Endocrine: denies polydipsia, polyphagia, heat or cold intolerance, goiter, excessive sweating,

Psychiatric: Denies depression/sadness, anxiety, obsessive/compulsive disorder, seeing a mental health professional, medication

Physical exam:

Vitals: T 98.4F orally, HR 68 regular, BP 132/86 sitting, height 5 ft 8 inch, weight 150 lb, BMI 22.8.

General: 48M, alert and oriented X3, using a cane walk, limping gait, 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: surgical wounds in the process of healing on the right shoulder. Right shoulder approximately 5 cm wound, well approximated, pink granulation tissue, no erythema or swelling or pus from surrounding area. Right foot approximately 3 cm wound, pink granulation tissue, no pus or erythema, mild swelling noted.  no rashes, bruises. No pallor noted.

Extremity:  right shoulder range of motion limited to pain. Full range of motion of the right ankle and toes. Sensation and pulses intact, no tightness in the area. full range of motion, strength grossly intact in upper and lower extremity on the left side. 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. Pain due to surgery
2. Pain due to healing fractures
3. Compartment syndrome (unlikely)

Assessment: 48M with 5 pack years, presented to primary care office with complaint of right foot and right shoulder pain, present since his motorcycle accident/orthopedic surgery in April 2021. He presented due to running out of his pain medication. Physical exam reveals well healing surgical wounds, mild non-concerning edema on the foot. No signs of infection or compartment syndrome.

Plan:

# right shoulder and foot pain due to motorcycle accident and subsequent surgeries.

1. Tylenol 650 mg every 4-6 hours PRN, Naproxen 500 mg every 12 hours PRN for pain
2. Advised patient to keep follow up appointment with orthopedics
3. Advised patient on signs and symptoms of infection and compartment syndrome
4. Patient counseled regarding possibility of future MRIs and that he now has metal implants

#smoking

1. Patient counseled regarding smoking cessation. Denies desire to quit at the current visit, citing stress from the accident

Identifying data

Name: DM

Sex: Female

Age: 18

Date and time: 6/4/21, 9:00AM

Race: Black 

Location: Amazing Medical Services, PC, Jamaica, Queens

Source of information: self, reliable

Chief complaint: “enlarged lymph node” x 2 years

HPI: DM is an 18-year-old female with no PMH presented to the family medicine office with complaints of enlarged lymph nodes for two years. She noticed a lymph node on the left posterior side of her neck two years ago. She said it changes in size, occasionally increasing in size and then becoming smaller again, and is intermittently painful. The pain when it occurs is throbbing, 4/10, no aggravating or remitting factors. In march of 2021 she noticed an additional lymph node on the posterior right side of her neck, but has not changed in size or been painful since she noticed it. Her childhood history is significant for several cases of tonsillitis, and she has not had her tonsils removed. Two years ago she was evaluated for the enlarged lymph node and had a soft tissue US of the neck which did not yield results indicative of a malignancy. She admits to a sore throat every morning for the past few months that is relieved with water. She denied enlarged lymph nodes elsewhere, earache, weight loss, fever, night sweats, bruising, cough, fatigue, feeling tired, having ever been sexually active or recent travel. She came in today because she was concerned about the increasing number of lymph nodes in her neck.

Past medical history:

cervical lymphadenopathy X 2 years

Childhood illnesses: tonsillitis

Hospitalizations: denies

Immunizations: up to date on vaccinations, has received both doses of covid Pfizer vaccine

Past surgical history: denies

Medications: denies taking medications on a daily basis

Allergies: denies allergies to medications, food or environment

Family history:

Paternal grandfather: deceased from liver cancer, diagnosed in 70s.

Mother: alive and well

Father: alive and well

Sister: alive and well

Denied knowing other grandparents’ family history, denied family history of cardiac disease, thyroid disease, kidney disease, lung disease, allergies, GI disease, urinary tract disease, psychiatric disease, nervous disorder, metabolic or endocrine disorders.

Social history:

Habits: denies smoking, including vaping. Denies drinking, denies use of recreational drugs

Travel: denies recent travel

Occupation: Freshman in college, studying biology

Home: lives at home with parents and sister

Diet: fruit/eggs/breakfast sandwich. salad/pizza. Animal protein/vegetable/grain.

Sleep: sleeps approximately 6 hours per night

Exercise: runs several times a week. 

Review of Systems:

General: denied nausea and loss of appetite, 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: admits to swollen lymph nodes, sore throat, denied vertigo, rhinorrhea, stuffiness, sneezing, 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

Breast: patient denied skin changes, nipple discharge

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

Peripheral vascular: Denies intermittent claudication, coldness, trophic changes, varicose veins, peripheral edema, color changes

Endocrine: denies polydipsia, polyphagia, heat or cold intolerance, goiter, excessive sweating,

Psychiatric: patient denied anxiety, depression, mood changes.

Physical exam

Vitals: 97.9 F orally, HR 84 regular, BP 124/74 seated, height 5 ft 5 inch, weight 145 lb, BMI 24.1, RR 16 unlabored,  O2 saturation 99% on room air

General: 18 Female, alert and oriented, in no acute distress, 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: asymmetrical left posterior cervical lymph node noted at base of the neck, approximately 1 cm, nontender and mobile, right posterior cervical lymph node noted at the base of the neck, <1 cm mobile and nontender. mucus membranes moist, no erythema or exudate in the back of the throat.  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.

Breast: no supraclavicular, axillary lymph nodes noted

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

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. Reactive lymph node from history of infections
2. Lymphoma
3. Leukemia
4. HIV

Assessment: 18-year old female with no PMH presents to primary care with complaint of swollen lymph nodes. Left posterior cervical lymph node present for 2 years, right posterior cervical lymph node present since 3/21. No family history of leukemia/lymphoma. Personal history of several episodes of tonsilitis. Denies sexually activity. Physical exam reveals asymmetric, nontender, mobile lymph nodes in the posterior cervical region.

Plan:

#cervical lymphadenopathy likely due to reactive lymph nodes

1. CBC
2. Fifth generation HIV test: denies sexual activity but has never been screened
3. Soft tissue neck US