History and Physical I

Devora Schapiro

History and Physical I

Internal Medicine


History: 9/24/19 9:30 AM

Identifying data:

Name: R. C.

Age/DOB: 91, 7/15/28

Sex: Male

Marital status: widowed (14 years)

Race: Caucasian

Nationality: Ireland

Address: Jackson Heights, NY

Religion: denies

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.

Family History:

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.

Social History:

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.

Vital Signs:

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

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