H&P 1

Identifying data: 

Name: M. F. 

Address: Queens, NY

Age: 60

Sex: Female

Date and time: 11/10/21, 10:30AM

Location: New York Presbyterian, Queens, NY

Religion: Catholic

Marital status: divorced

Source of information: self and medical records

Reliability: reliable

Chief complaint: “  bumps on my face” X 3-4 months 

History of present illness: M.F. is a 60 year-old female with PMH of GERD, who presented to the ED with several red bumps on her face for the past 3-4 months. In July of 2021 the patient was in Colombia (the country) and received cosmetic injections of deoxycholic acid in her submental region. In August of 2021 several raised red bumps developed on her face. The bumps are painful and hard red and swollen, and she says “more and more keep popping up” but no drainage has been noted. Patient has been to see an outpatient dermatologist and tried 4 different oral antibiotics (unable to recall the names) outpatient without success. Patient saw an infectious disease specialist last week who cultured one of the bumps, which tested positive for Mycobacterium. Patient came to the ED today because she began suffering from fever, chills and a nonproductive cough earlier this week. Patient admits to fever, cough, facial swelling, neck swelling, and facial pain. Patient denies hemoptysis, night sweats, unintended weight loss, chest pain, nausea, vomiting, abdominal pain, headaches, changes in vision, dysphagia, difficulty breathing. 

ED course: patient was given an LR fluid bolus, and IV Azithromycin and Imipenem according to infectious disease recommendations. CT neck and chest were obtained. 

Past medical history: 

GERDX 10years 

Past surgical history: 

Cholecystectomy, six years ago at Mount Sinai for acute cholecystitis. No complications. 

Medications: 

Pantoprazole 40 mg daily, for GERD

Allergies: patient denies allergies to medication, food or environment 

Family history: 

Grandparents: unknown 

Parents: deceased, unknown history 

Siblings: alive, unknown history

Son: alive and well 

Denied family history of cardiac disease, metabolic disorders, cancer, thyroid disease, kidney disease, allergies, lung disease, GI disease, urinary tract disease, psychiatric disorders, nervous disorders.

Social history: 

Marital status: divorced, lives alone

Occupation: retired teacher 

Habits: admits to a single glass of wine weekly, patient denied smoking, use of recreational drugs. 

Travel: Colombia (the country) July 2021. 

Diet: breakfast fruit/coffee, lunch sandwich (tuna/egg salad/deli meat), dinner salad or protein. 

Exercise: walks to do shopping several times a week

Sleep: sleeps between 7-8 hours a night.

Sexual history: not sexually active

Review of systems: 

General: admits to fever, chills, patient denied nausea, anorexia, general weakness,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: denied blurred vision, itching, photophobia, discharge, swelling. Does not wear corrective lenses

ENT: admits to neck pain, facial pain, swelling.  patient denied vertigo, rhinorrhea, stuffiness, sneezing, sore throat, swollen lymph nodes, tinnitus, ear pain, deafness, use of hearing aids

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

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

Hematology: patient denied bruising, anemia, enlarged lymph nodes, history of DVT/PE

Skin: admits to several raised, red, swollen painful bumps on neck and face, patient denied rash, sores, itching 

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

GU: patient denied urgency, dysuria, polyuria, hematuria, nocturia, incontinence. Patient is postmenopausal at 60, denies dysparenuia, dryness, itching. Patient is G1P1 NSVD.

MSK: patient denied joint pain and swelling 

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

Psychiatric: patient denied anxiety, depression, mood changes.

Physical exam: 

Vitals: temperature 100.9 F, pulse oximetry 96% on RA , HR 84 regular, BP 134/76  mmHg, RR 16 unlabored. Height 5’3”, weight 145 lb.

General: 60 female, alert and oriented X3, overweight, appears stated age

Head: normocephalic and atraumatic, non tender to palpation

Eyes:symmetric OU,  no eyelid swelling or ptosis, lesions noted externally. PERLL, non icteric, no conjunctival injection. Visual fields full by confrontation bilaterally. EOMIs. 

ENT:  multiple small areas of indurated skin on face and anterior neck, overlying skin darkened, tender to palpation. No drainage. Airway patent. mucus membranes moist, no erythema or exudate in the back of the throat, no lymphadenopathy. Trachea midline, thyroid not-enlarged. Uvula midline. Dentition intact, no obvious caries. 

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: clear to auscultation bilaterally,  Normal respiratory effort, no retractions. Symmetrical chest expansion, no wheezing or rhonchi, crackles. 

Abdominal: bowel sounds present in all four quadrants, abdomen soft and non tender, with no distention, no hepatosplenomegaly. No guarding or rebound noted. No abdominal pulsations or bruits. 

Skin: see ENT,  no rashes, bruises or scars. No pallor noted. Warm and moist, non icteric skin. Normal skin turgor.

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. Sensation intact. 

Neurological: patient is able to ambulate normally, finger to nose normal. Sensation to face intact. Jaw strength, facial movements, shoulder shrug, EOMIs with no nystagmus. 

Labs: 

1. BMP and electrolytes: Na 141, K 4.1, Cl 103, CO2 28, BUN 11, Cr 0.62, glucose 125
2. CBC: WBC 7.70, RBC 3.65, Hgb 13.3 Hct 40.8, platelets 321
3. LFT: total protein 7.6, albumin 4.8, total bilirubin 0.2, direct bilirubin 0.1, AST 19, ALT 20, ALP 84 
4. CRP <0.30 
5. Covid: negative 

Imaging: 

1. CT chest: 2-3 mm nodular opacity in the posterior inferior lateral right upper lung lobe. Airways were clear, no enlarged lymph nodes, cannot rule out active mycobacterial disease at this time
2. CT neck: multiple facial foci of the skin were thickened superficially which corresponds to superficial abscesses. No abscesses in deeper soft tissue. No enlarged lymph nodes. 

Assessment: 

60-year old female with PMH of GERD presented to the ED with several months of facial abscesses positive for Mycobacterium with associated fever, chills and cough. 

Plan: 

# facial/neck abscesses s/p cosmetic injections in July 2021, outpatient culture positive for Mycobacterium 

1. Failed outpatient treatment X4
2. Admit to medicine team 
3. Treat with IV antibiotics as per infectious disease recommendations
   1. IV imipenem 500 mg/100 mL Q8 hours
   2. IV Azithromycin 500 mg/250 mL Q24 hours
4. Blood cultures X 2  

#incidental finding of right upper lobe 2-3 mm nodule on CT 

# cough in the setting of CT finding and outpatient culture positive for mycobacterium 

1. Rule out tuberculosis
   1.  Sputum acid fast bacilli cultures X 3
   2. Quantiferon gold test 
2. Respiratory isolation 
3. Trend temperature, WBC and respiratory status  

#History of GERD

1. Continue home pantoprazole 40 mg daily 

# DVT prophylaxis 

1. Lovenox 40 mg subcutaneous 

H&P 2

Identifying data: 

Name: T.M. 

Address: Queens, NY

Age: 52

Sex: Male

Date and time: 11/19/21 4:00AM

Location: New York Presbyterian, Queens, NY

Religion: Muslim

Marital status: married

Source of information: self and medical records

Reliability: reliable

Chief complaint: “ chest pain” X 2 weeks 

History of present illness: T.M is a 52 year-old male active pack a day smoker, with PMH HTN, HLD, and DM presented to the ED with exertional chest pain for the past 2 weeks. Chest pain has been worsening over the past two days with exertion. It is located over the upper mid chest, described as pressure, radiates to the back, ranging from 5-8/10. Chest pain is associated with palpitations and SOB. Prior to a few days ago he could walk several blocks without SOB but currently he becomes SOB at half a block. SOB improves with rest, but chest pain remains although lessens 3-4/10. He has not had a similar presentation in the past. He denies diaphoresis, orthopnea, PND, leg swelling, fatigue, weakness, loss of appetite, change in mental status, cough, sputum, fever, chills, IV drug use, sick contacts, recent travel, nausea, vomiting, diarrhea/constipation. 

In the ED ECG was normal but the patient was found to have elevated troponins. Patient was given IV heparin and Aspirin.

Currently the patient reports chest pain 4/10, but denies SOB in bed. 

Past medical history: 

DM X 10 years

HLDX 15 years

HTNX 15 years  

Past surgical history: 

Umbilical Hernia repair in 2011, unsure which hospital. Denies complications. 

Medications: 

Farxiga 10 mg daily for diabetes

Diltiazem 120 mg daily for HTN

Lisinopril 2.5 mg daily for HTN

Metformin 1000 mg daily for DM 

Metoprolol tartrate 100 mg daily for HTN

Rosuvastatin 20 mg daily for HLD

Allergies: patient denies allergies to medication, food or environment 

Family history: 

Grandparents: unknown 

Father: deceased from MI at age 57

Mother: alive, unknown history

Siblings: alive, unknown history

Son  and daughter: alive and well 

Denied family history of metabolic disorders, cancer, thyroid disease, kidney disease, allergies, lung disease, GI disease, urinary tract disease, psychiatric disorders, nervous disorders.

Social history: 

Marital status: married lives with wife

Occupation: works at grocery store

Habits: smokes 1 pack of cigarettes daily, denies alcohol use and use of recreational drugs. 

Travel: denies

Diet: breakfast eggs/bagel/cereal. Lunch meat sandwich. Dinner meat/vegetables/starch 

Exercise: walks 

Sleep: sleeps between 7-8 hours a night.

Sexual history: sexually active with wife

Review of systems: 

General: patient denied fever, chills, nausea, anorexia, general weakness,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: denied blurred vision, itching, photophobia, discharge, swelling. Does not wear corrective lenses

ENT: patient denied vertigo, rhinorrhea, stuffiness, sneezing, sore throat, swollen lymph nodes, tinnitus, ear pain, deafness, use of hearing aids

Cardiac: see HPI. patient denied leg edema, claudication, known heart murmurs

Pulmonary: see HPI, denied cough,pain with inspiration, wheezing, hemoptysis 

Hematology: patient denied bruising, anemia, enlarged lymph nodes, history of DVT/PE

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 

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

Psychiatric: patient denied anxiety, depression, mood changes.

Physical exam: 

Vitals: temperature 36.8 C, pulse oximetry 95% on RA , HR 103 regular, BP 126/82  mmHg, RR 18 unlabored. Height 167.6 cm weight 91.2 kg BMI 32.5

General: 52 male,  alert and oriented X3, overweight, appears stated age

Head: normocephalic and atraumatic, non tender to palpation

Eyes:symmetric OU,  no eyelid swelling or ptosis, lesions noted externally. PERLL, non icteric, no conjunctival injection. Visual fields full by confrontation bilaterally. EOMIs. 

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

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: clear to auscultation bilaterally,  Normal respiratory effort, no retractions. Symmetrical chest expansion, no wheezing or rhonchi, crackles. 

Abdominal: bowel sounds present in all four quadrants, abdomen soft and non tender, with no distention, no hepatosplenomegaly. No guarding or rebound noted. No abdominal pulsations or bruits. 

Skin:  no rashes, bruises or scars. No pallor noted. Warm and moist, non icteric skin. Normal skin turgor.

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. Sensation intact. 

Neurological: patient is able to ambulate normally, finger to nose normal. Sensation to face intact. Jaw strength, facial movements, shoulder shrug, EOMIs with no nystagmus. 

Labs: 

1. BMP and electrolytes: Na 141, K 3.9, Cl 104, CO2 25, BUN 7.1, Cr 0.86, glucose 89 Ca: 9.3 Phosphate: 3.4
2. CBC: WBC 9.80, RBC 5.19 Hgb 12.6 Hct 40.5, platelets 416
3. Troponin: 0.025→ 0.028 
4. aPTT baseline: 28.8 
5. D-dimer: <150 (0-229)
6. Covid: negative 

Imaging: 

1. CXR: no evidence of acute cardiopulmonary disease. 
2. EKG: sinus tachycardia at 106, no acute ST/T changes  

Assessment: 

52-year-old male, smoker with PMH of HTN, HLD, and DM presenting with exertional chest pain. ECG normal with elevated first  troponin 0.025, d-dimer <150, PTT 28.8, negative Covid. Started on heparin and ASA in the ED. patient will be admitted for ACS workup  

Plan: 

# chest pain due to NSTEMI 

1. Repeat troponins, repeat ECG, telemetry monitoring 
2. Echocardiogram this AM 
3. Cardiac catheterization lab this AM 
4. Diet: NPO besides for medications
5. Cardiac consult- follow up recommendations 
6. Start with nitroglycerin 0.4 mg SL for pain PRN (hold if inferior wall MI)
7. Continue with Heparin drip 1000 U/ hour
   1. Check PTT Q6 hours to gaol of 50-75 therapeutic)
8. Continue with Aspirin 81 mg daily 

# HTN

1. Continue with metoprolol 100 mg, lisinopril 2.5 mg, diltiazem 100 mg. 
2. Monitor blood pressure 

#HLD

1. Start Lipitor 80 mg 
2. Send lipid profile 

#DM

1. Insulin lispro sliding scale 
2. Send HbA1C

#DVT prophylaxis 

1. Patient is on a heparin drip 

H&P 3

Identifying data: 

Name: P.Y.

Address: Queens, NY

Age: 73

Sex: Male

Date and time: 11/16/21 2315 

Location: New York Presbyterian, Queens, NY

Religion: denies 

Marital status: married 

Source of information: self and medical records

Reliability: reliable

Chief complaint: Fall three days ago

History of present illness: P.Y. is a 73M with PMH of HTN, CAD s/p PCI in 2017 with DESX1, PVD s/p R external iliac stent and R femoral-popliteal graft in 7/2018 on ASA s/p 4 toe amputation on right 10/2018, HFrEF (EF 35%) with history of alcohol abuse (drinks 1 L of vodka daily), insulin dependent DM, 50 pack years,  presented to the ED for a witnessed fall today. Patient states he has had trouble walking this past month at home due to feeling unbalanced. He has been able to ambulate only with a walker over the past month. Today he stood up and went to hold his walker, he fell down and hit the back of his head. Fall was witnessed by wife, both denying LOC. the patient states he lost his balance and fell. The patient denies headache, blurry vision, neck pain, chest pain, SOB, palpitations, fever, chills, dizziness, lightheadedness, unilateral weakness, sensory loss, nausea, vomiting, denies sick contacts, recent travel. Patient reports he has self discontinued all his medications for the past month.

Past medical history: 

HTNX 25 years

DMX 20 years

CAD X5 years 

PVD X 4 years

HFrEF X 5 years (EF 35%)

Alcohol abuse X 20 years (1L of vodka daily)

Past surgical history: 

PCI in 2017 for CAD with DES X1 

Right external iliac stent, right femoral popliteal graft in 2018 for PVD 

 4 right toe amputations in 2018 for PVD unviable tissue 

Medications: patient has been non compliant with home medications for a month

Apixiban 5 mg two tablets PO BID 

Aspirin 81 mg PO daily 

Carvedilol 12.5 mg PO BID

Nifedipine 30 mg PO daily

Lantus 10 units SC nightly 

Allergies: penicillins (Rash). Denies allergies to food or environment

Family history: 

Grandparents: patient did not know

Parents: deceased, patient did not know

Denied family history of cardiac disease, metabolic disorders, cancer, thyroid disease, kidney disease, allergies, lung disease, GI disease, urinary tract disease, psychiatric disorders, nervous disorders.

Social history: 

Marital status: married lives with wife

Occupation: retired construction worker 

Habits: drinks 1 L of Vodka daily. 50 pack year smoking history quit last year 

Travel: denies recent travel 

Diet: has poor appetite 

Exercise: denies exercising 

Sleep: sleeps between 7-8 hours a night.

Sexual history: sexually active with wife 

ADLs: dependent on wife for help with ADLs

PMD: Dr. Smith in Queens at 718-000-0000 has not been to see in >2 years due to covid 

Review of systems: 

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

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

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

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

ENT:  patient denied vertigo, rhinorrhea, stuffiness, sneezing, sore throat, swollen lymph nodes, tinnitus, ear pain, deafness, neck pain, use of hearing aids

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

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

Hematology: patient denied bruising, anemia, enlarged lymph nodes, history of DVT/PE

Skin: patient denied rash, sores, itching 

GI: patient denied bowel changes, abdominal pain, diarrhea, constipation, dysphagia. Never had a colonoscopy.

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

MSK: patient denied joint pain and swelling 

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

Psychiatric: patient denied anxiety, depression, mood changes.

Physical exam: 

Vitals: temperature 37.2 C  pulse oximetry 98% on RA , HR 98 regular, BP 165/90  mmHg, RR 20 unlabored. Height 1.854 m weight 61.7 kg BMI 18

General: 73M alert and oriented X3, thin, appears stated age

Head: mildly tender in the occipital region to palpation

Eyes:symmetric OU,  no eyelid swelling or ptosis, lesions noted externally. PERLL, non icteric, no conjunctival injection. Visual fields full by confrontation bilaterally. EOMIs. 

ENT: mucus membranes dry, no erythema or exudate in the back of the throat, no lymphadenopathy. Trachea midline, thyroid not-enlarged. Uvula midline. Dentition intact, no obvious caries. 

Cardiac: regular rate and rhythm, S1 and S2 auscultated. no murmurs, rubs or gallops.

Pulmonary: clear to auscultation bilaterally,  Normal respiratory effort, no retractions. Symmetrical chest expansion, no wheezing or rhonchi, crackles. 

Abdominal: bowel sounds present in all four quadrants, abdomen soft and non tender, with no distention, no hepatosplenomegaly. No guarding or rebound noted. No abdominal pulsations or bruits. 

Skin:  no rashes, bruises or scars. No pallor noted. Warm and moist, non icteric skin. Normal skin turgor.

Extremity: healed ulcer on left foot. Right foot with 1 toe. full range of motion, strength grossly intact in upper and lower extremity. No unilateral calf swelling or tenderness. No clubbing, cyanosis or edema. Sensation intact. 

Neurological: patient is unable to ambulate without assistance, finger to nose normal. Sensation to face intact. Jaw strength, facial movements, shoulder shrug, EOMIs with no nystagmus. 

Labs: 

1. BMP and electrolytes: Na 139, K 4.5, Cl 98, CO2 26, BUN 14.2, Cr 0.97, glucose 146
2. CBC: WBC 6.30, RBC 5.02, Hgb 13.1 Hct 41.7, platelets 249
3. Ethanol level: 225 mg/dL  
4. Covid PCR: negative 
5. Troponin: negative X 2

Imaging: 

1. CT cervical spine without contrast: dens and occipital condyles intact. No acute displaced fracture. Mild cervical spondylosis on multiple levels.  
2. CT head without contrast: no CT evidence for acute intracranial pathology
3. ECG: NSR at 94 BPM no ST segment changes  

Assessment: 

73 yo M with PMH of HTN, DM, CAD s/p PCI in 2017 with DES x1, PVD s/p right external iliac stent and right femoral-popliteal graft 7/2018 on ASA, s/p 4 toe amputation on right foot 10/2018, HFrEF (EF 35%), alcohol abuse (1 L of vodka daily) presented with fall today after losing his balance. Will admit for monitoring. 

Plan: 

#witnessed fall without acute injuries seen on imagin 

1. No skin breakage
2. CT head and C spine with no acute traumatic injuries 
3. Likely secondary to alcohol abuse (ethanol level 225 mg/dL)

#EtOH abuse impending withdrawal 

1. CIWA protocol 
   1. Ativan 0.5 mg every hour PRN
2. Thiamine 100 mg tablet daily 
3. Folate 1 mg daily 
4. IV NS 75 cc hr maintenance fluid 
5. Fall precautions 
6. Social worker for AA referral and rehab recommendations 

#HTN, CAD, PVD

1. Patient non compliant with home medications for one month. Patient used to take carvedilol 12.5 mg, nifedipine 30 mg, apixaban 5 mg, aspirin 81 mg
2. Will restart carvedilol, apixaban, and aspirin 

# insulin dependent DM 

1. Patient non compliant with medication for 1 month, patient used to take Lantus 10 U nightly 
2. Will start patient in Lispro sliding scale 
3. f/u HbA1C 
4. Diabetic diet 

#DVT prophylaxis 

1. Patient restarted on home apixaban 5 mg daily 

#activity 

1. Out of bed with assistance
2. PT consult