History and Physical I
History: 9/24/19 9:30 AM
Name: R. C.
Age/DOB: 91, 7/15/28
Marital status: widowed (14 years)
Address: Jackson Heights, NY
Location: New York Presbyterian Queens
Source: Self, unreliable
Referral: daughter, patient unable to remember primary care provider name
Chief complaint: “I don’t know how I got in here” X1 day
History of Present Illness: R. C. is a 91 year old male with a past medical history of hypertension, hyperlipidemia, and coronary artery disease. Patient was first unsure why he came and when he came in. After denying all symptoms at first patient admitted to difficulty speaking, a quieter voice, unsteady gait, tiredness, and weakness. The difficulty speaking came on over a period of several months, was persistent, lasting for several months. Patient was unable to describe location, treatment, or worsening/alleviating factors. Patient admits to past history of high blood pressure. Patient denies headaches, dyspnea, chest pain, past history of smoking, diabetes, and family history of stroke. Patient was agitated and worried about being alone with no one in his family knowing where he was. Chief PA-C stated daughter brought him to emergency department four days ago after noticing unsteady gait.
Past Medical History:
present medical illnesses: hypertension X30 years, hyperlipidemia unknown duration, coronary artery disease X30 years
past medical illnesses: patient admits to being hospitalized infrequently but does not remember why
childhood illnesses: chickenpox
immunizations: up to date
screening tests: doesn’t know
Past Surgical History: open heart surgery 30 years ago, Princeton hospital, does not know why, no complications. Admits to “broken knee” 30 years ago treated at Princeton hospital. Patient is unsure about transfusions. Denies other surgeries
Medications: Patient does not know names, doses, or when he last took any of his medications. Patient denies vitamins or supplements.
Allergies: Patient states he has medication allergies but cannot remember the day or reaction. Patient thinks he is allergic to an antibiotic. Patient denies environmental or food allergies.
Mother- deceased, 95, unknown reason
Father- deceased, 65, unknown reason
8 children (4 boys, 4 girls) ages ranging 47-61 (does not know specific ages), alive and well
maternal/paternal grandparents- unknown
Admits to family history of hypertension. Denies family history of allergies, heart disease, lung disease, GI disease, cancer, urinary tract disease, psychiatric, nervous, metabolic, endocrine, thyroid.
Habits- admits to occasional glass of wine with dinner, 3 cups of coffee a day, denies smoking and drug use
Travel- denies recent travel, military
Marital- widowed, lives in senior facility
Occupation- retired at 65 years
Home- senior care facility, no pets
Diet- coffee, egg, cereal, juice
Sleep- sleeps well at night
Exercise- walks with assistance, cane or walker
Safety- does not drive any more
Review of Systems:
General: Admits to weakness and generalized fatigue. Denies recent weight loss or gain, loss of appetite, fever, chills, night sweats.
Skin, hair, nails: Denies changes in texture, hair distribution. Denies excessive dryness, sweating, discolorations, pigmentation, moles, rashes, pruritus
Head: Admits to head trauma due to falls, unsure how recent. Denies unconsciousness, coma or fracture. Denies headache, vertigo, and lightheadedness
Eyes: Denies visual disturbances, lacrimation, photophobia, pruritus. last eye exam- a month ago, wears glasses, doesn’t know prescription.
Ears: Admits to deafness, normally wears hearing aids. Denies pain, discharge, tinnitus
Nose: Denies discharge, epistaxis, obstruction
Mouth and Throat: Admits to quieter voice. Denies bleeding gums, sore tongue, sore throat, mouth ulcers, dentures. Last dental exam approximately 1 month ago, required tooth to be pulled.
Neck: Denies localized swelling, lumps, stiffness, decreased range of motion
Breast: Denies lumps, nipple discharge, pain
Pulmonary: Admits to cough without expectoration. Denies dyspnea, wheezing, hemoptysis, cyanosis, orthopnea, paroxysmal nocturnal dyspnea
Cardiovascular: Admits to hypertension. Denies chest pain, palpitations, irregular heartbeat, edema, syncope, known heart murmur
GI system: Denies any changes in appetite, intolerance, nausea, vomiting, dysphagia, pyrosis, flatulence, eructations, abdominal pain, diarrhea, jaundice, change in bowels, hemorrhoids, constipation, rectal bleeding, blood in stool
Genitourinary system: Admits to frequency, urgency. Denies nocturia, oliguria, polyuria, dysuria, incontinence, awakening at night to urinate, pain in flank. Denies prostate exam, hesitancy and dribbling
Sexual: not currently sexually active. Previous partner women. Denies impotence, sexually transmitted infections
Nervous system: Admits to loss of strength, weakness. Denies seizures, headaches, loss of consciousness sensory disturbances, ataxia, change in cognition.
Musculoskeletal: Denies muscle/joint pain, deformity, swelling, redness, arthritis
Peripheral vascular system: Denies intermittent claudication, coldness, trophic changes, varicose veins, peripheral edema, color changes
Hematologic: Admits to easy bruising. Denies anemia, easy bleeding, lymph node enlargement, history of DVT. Patient doesn’t know about blood transfusions.
Endocrine system: Denies polyuria, polydipsia, polyphagia, heat or cold intolerance, goiter, excessive sweating, hirtuism
Psychiatric: Denies depression, sadness, anxiety, obsessive/compulsive disorder, medications or seeing a mental health professional
General Survey: Patient is a 91 year old male, alert and oriented X1 to person. Patient has small build, patient is well groomed and does not appear to be in distress.
Blood pressure: supine: Right arm 152/76, left arm 152/78. Sitting: Right arm 154/80, left arm 158/76
Respirations: 17 breaths per minute, unlabored
Heart Rate: 69 beats per minute, regular rhythm
Temperature: 37.6 degrees Celsius, orally
Pulse Oxygen: 98% on room air
Height: 5 feet 8 inches Weight: 159 pounds BMI: 24
Skin: scar along midline of chest. Skin is warm and moist with good turgor, non icteric, no lesions or tattoos noted.
Hair: sparse and thin
Nails: no clubbing, capillary refill less than 2 seconds
Head: normocephalic, atraumatic, non tender to palpation throughout
History and physical IV
History: 2/18/2020 7:50 AM (E.D.)
Age/DOB: 70, 05/25/1949
Marital status: single, divorced
Address: Jackson Heights, NY
Sources: self, reliable
referrals: self, PCP: Dr. Kim
Chief Complaint: “I have been coughing very profusely” X2 days
History of Present Illness: M.M. is a 70 year old male with past medical history of asthma, chronic bronchitis, pulmonary embolism, and anxiety. He denies smoking. He complains of a productive cough with clear sputum, that began two days ago. He used his albuterol inhaler and Advair but they did not help as they usually do. Patient has associated chest pain/tightness in the center of his chest. He admits to full body muscle pain and weakness that is 8/10. The cough came on gradually and has been intermittently present for the past two days. He took 500 mg of Tylenol which helped the pain, and alkaseltzer which did not. Patient states that his asthma medication has always helped his cough in the past. Patient denies recent travel or contact with sick individuals. Patient admits to subjective fever, shortness of breath, sweating, chills, weakness, headache, chest pain, nausea, loss of strength, palpitations, sore throat, pruritic eyes. Patient denies loss of appetite, abdominal pain, hemoptysis, wheezing, discharge from nose. Patient states that he came in today because he was feeling so weak he could not a cup of coffee.
Past medical History:
Present illness: eczema X2 months, anxiety X7 years, asthma X18 years, chronic bronchitis X18 years
Past medical illness: pneumonia X19 year ago, PE in 2007
Childhood illness/ immunization: denies, up to date on immunizations, received the flu shot this year
Past Surgical History:
procedures: retinal detachment repair, OD, 2004, sequela from trauma
jugular vein repair, right side, 2004, trauma
injuries: gun shot wound right neck/head, 2004
transfusions: blood during trauma repair surgery, not sure what type, how much etc.
complications: decreased sensation on right side
Advair/Fluticasone salmeterol- for asthma, last taken this morning, doesn’t know dose, inhaled
Zyrtec/cetirizine- for allergies, last taken this morning, doesn’t know dose, oral
Albuterol inhaler- asthma, last used this morning
Cortisone 10 creme- for eczema, last used this morning
Alprazolam- for anxiety last taken week ago, doesn’t know dose
Denies vitamins or holistic preps
no known drug allergies, Environmental: dogs, cats. Food: no known allergies
family history: father- deceased, 78, prostate cancer. Mother- deceased, 79 kidney failure, hypertension. Brother: doesn’t know medical history, 73. 4 children: alive and well. Doesn’t know grandparents medical Hx. Denies family history of allergies, heart disease, lung disease, GI disease, psychiatric, nervous disorders, metabolic , endocrine disorders
Social History: habits: alcohol: 1 glass of wine, weekly, denies smoking, coffee 1 cup a day. Travel: denies recent travel. Martial history: 2x divorced. Occupational History: retired, disabled, emergency medicine administrator. Home: roommate , no pets
Diet: breakfast- coffee/juice, lunch/dinner: heavy meal, variety, tea, pastries. Sleep: sleep apnea (not diagnosed). Exercise: 3x a week stair master for 1 hour, stretching, 3x week yoga. Safety: doesn’t drive.
Review of systems: General: admits to generalized weakness, fever and chills. Denies recent weight loss/ gain, loss of appetite, fatigue, night sweats. Skin, hair, nails: admits to pruritus, denies changes to texture, hair distribution, excessive dryness or sweating, discolorations, pigmentations, moles, rashes. Head: admits to headache which is relieved by Tylenol (current, not regular headaches), vertigo, recent head trauma. Eyes: admits to pruritus, denies visual disturbances, lacrimation, photophobia, Sees ophthalmologist biannually due to sequelae from shooting, wears reading glasses, unknown prescription. Ears: admits to pain and pruritus, occasional bloody discharge, denies deafness, tinnitus, use of hearing aids. Nose/sinus: denies discharge, obstruction, epistaxis. Mouth/throat: admits to sore throat, denies bleeding gums, sore tongue, mouth ulcers, voices changes, last dental exam was 2 weeks ago for denture maintenance, both top and bottom. Neck: admits to stiffness, denies swelling or lumps. Breast: denies lumps, nipple discharge, pain. Pulmonary: admits to dyspnea, productive cough with clear salty sputum, sleep apnea. Cardiovascular: admits to chest pain, palpitations, denies HTN, irregular heartbeat, edema of ankles, feet, syncope, known heart murmur. GI: admits to pyrosis, eructation’s, intolerance to fatty and fried foods, nausea. Denies changes to appetite, vomiting, dysphagia, flatulence, abdominal pain, diarrhea, jaundice, change in bowel habits, hemorrhoids, constipation, rectal bleeding. Colonoscopy 6 years ago, several polyps were removed during procedure. GU system: admits to frequency, nocturia (5x a night), denies urgency, oliguria, polyuria, dysuria, discolored urine, incontinence, pain in flank. Last prostate exam a year ago, doesn’t know results. Denies hesitancy, dribbling. Sexual: denies sexual activity, history of sexually transmitted infection. Nervous: admits to headaches, loss of strength, short term memory loss from gun shot wound, weaker right side. Denies seizures, loss of consciousness, sensory disturbances, ataxia. MSK system: denies muscle/ joint pain, arthritis. Peripheral vascular: denies intermittent claudication, coldness, varicose veins, peripheral edema, color changes. Hematologic: admits to blood transfusion, history of PE in 2007, denies anemia, easy bruising, bleeding, lymph node enlargement. Endocrine: denies polyphagia, polydipsia, polyuria, goiter, heat/cold intolerance, excessive sweating. Psychiatric: admits to anxiety, saw mental health professional in the past, takes alprazolam, denies depression, sadness, OCD.
General survey: patient is a 70 y/o male, alert and oriented x3 to person, place, time. Patient thin, constantly coughing otherwise no distress, looks stated age.
Vitals: BP seated: R 138/82 L 136/70. Supine: R 136/80 L 136/88/ RR: 19 breaths/min unlabored, pulse: 99 beats/min regular. T: 37.2 C. O2 sat: 99% on room air. Height: 66 inch, weight: 108 lb, BMI: 17.4
Skin: well healed scar, right side lateral clavicular border to posterior auricular region. Warm and most, non-icteric, no other lesions, scars.
Hair: average quantity, distribution
Nails: no clubbing, capillary refill <2 seconds throughout
Head: normocephalic, atraumatic, nontender to palpation
Eye: symmetrical OU, no evidence of strabismus, exophthalmos or ptosis, sclera white, conjunctiva pink, and clear cornea. Visual acuity (20/20 OS, 20/20 OD, 20/20 OU) visual fields OU, PERRL. EOMs full, minimal nystagmus, fundoscopy- red reflex intact OU, cup: disc <0.5OU, no evidence of exudates, hemorrhaging, cotton wool spot, papilledema OU.
Ear: symmetrical normal size, no lesions, asses, trauma on external ears. No discharge, foreign bodies in auditory canal AU. TMs pearly white, non distorted cone of light AU. Auditory acuity intact to whisper AU, weber midline, Rinne AC>BC AU.
Nose: symmetrical, no masses, lesions, deformities, trauma, discharge. Nares patent bilaterally, pink nasal mucosa, well hydrated. Septum midline, no deformities, lesions, injection, perforation, no foreign bodies.
Sinus: Frontal sinus tender to palpation and percussion, nontender maxillary.
Mouth: lips- pink moist, no lesions. Buccal mucosa- pink, well hydrated, no masses, leukoplakia, lesions, palate- pink, well hydrated, intact, no lesions, scars, masses. Teeth- good dentition, dentures. Gingivae- pink, moist, no hyperplasia, masses, lesions, erythema, discharge. Tongue- pink, well papillated, no masses, deviations. Oropharynx- well hydrated, no injection, exudate, masses, lesions, foreign bodies. Tonsils present no injection, uvula pink no lesions.
Neck: trachea midline, no masses, lesions, pulsations, non tender to palpation
Lungs/chest: symmetrical no deformities, no evidence of trauma, respirations unlabored, no paradoxical respirations or accessory muscle use, lat to AP diameter 2:1. Non tender to palpation, lungs clear to auscultation and percussion bilaterally, chest expansion and diaphragmatic excursion symmetrical, tactile fremitus intact throughout, no adventitious sounds.
Abdomen: flat, symmetric, no scars or striae, pulsations, normoactive bowel sounds in all four quadrants, no bruits noted. Nontender to palpation and tympanic throughout, no guarding or rebound noted, no hepatosplenomegaly to palpation, no CVA tenderness appreciated.
Cardiac: JVP 2.0 cm above sternal angle at 30 degrees. PMI in 5th ICS at midclavicular line, 2+ carotid pulses bilaterally, no bruits. Regular rate, rhythm S1 and S2 distinct, no murmurs, S3, or S4. No s2 splitting or friction rubs
Male and rectal: circumcised male, no penile discharge or lesions, no scrotal swelling or discoloration, testes descended bilaterally, smooth and without masses, epididymis non tender, 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, stool brown and hemoccult negative.
Assessment: 70 year old male with a PMH of asthma, chronic bronchitis, pulmonary embolism and anxiety. Non-smoker, presenting to the emergency department with two day history of productive cough and chest pain.
Differential diagnosis: Upper respiratory infection (cough, subjective fever, sore throat), acute coronary syndrome (chest pain, nausea, shortness of breath, sweating) pulmonary embolism (PMH, chest pain, shortness of breath, sweating), asthma exacerbation (PMH, cough, SOB, chest pain), pneumonia (cough, SOB, subjective fever, chest pain, weakness)
H&P Comparison and Analysis:
- What differences do you note between the two H&Ps?
In my first H&P the HPI was not as smoothly written, and as well organized as my more recent one. The HPI in my first one is slightly out of order, and some important information that should be included in a HPI was left out, whereas my more recent one was written mainly in order, although not perfect and included all relevant information.
- In what ways has your history-taking improved? Are you eliciting all the important information?
In my first H&P, I did not know which questions to ask the patient, because it was so early on in my PA education I hadn’t begun formulating differential diagnoses in my head when taking history. Being able to formulate a list of potential diagnoses in my head has improved my history taking because it leads me to ask certain questions to rule in and rule out diagnosis.
- In what ways has writing an HPI improved? (hint: look at the rubric scores)
In my earlier HPI I left out some information that I included in later parts of my H&P (ROS category) but that should have been included in my HPI portion since they were relevant to the story of the chief complaint. In my later HPI I was able to organize which information should be included in the HPI and which should be included later in the ROS or assessment, my rubric scores of my HPI corresponded with the changes and improvements I believe I have made.
- What is your self-assessment of your current skill in performing a physical exam? Which areas do you feel strongest about/weakest about?
I feel strongest about performing auscultations and palpation exams (abdomen, cardiac, pulmonary). I also feel comfortable with performing a basic neuro exam and CN exam. I feel my technique in those areas is strong. Some areas of physical exam I feel I need to improve on is the ENT exam, I would like to work on my fundoscopy examination as well as otoscopy, I am nervous in the otoscope exam about the technique of holding the scope and looking in a patient’s ear. I also would like to improve my physical exam skills in terms of recognizing when something is abnormal. Most of my practice has been on classmates which nearly all had normal physical exams, I think when I am out on my clinical rotations and I obtain a point of reference for abnormal findings I will feel altogether more confident in my physical exam skills.
- Of course we expect you to get stronger in all areas, but which of the specific areas will you target as needing particular focus in future patient visits when you start the clinical year?
I would like to improve the speed at which I ask questions to my patients, one of the ways I have improved is knowing which question to ask next/ follow up with, however it takes me sometime to organize that and ask the follow up question, I eventually get the information that is helpful for that patient case but the order and how quickly I am capable of coming up with follow up questions is something I want to improve on. I also would like to improve my bedside manner, I think that when I am pausing to write something down or thinking of the way to phrase my next question I am too silent, not expressive enough, not making enough eye contact with the patient, I think improving on my eye contact and interactions with patients for clinical year will be helpful in improving patient trust and patient-provider relationship. As mentioned above I would like to expand on my physical exam capabilities, I would like to experience a wide range of abnormal and normal findings so I can have a point of reference to really be confident in my physical exam findings.