3rd Hospital H&P

Preadmission testing – H&P – 3rd hospital visit

Blue color = info filled in/missed/unable to perform

Identifying information:

Full Name: Mrs. M.H.

Address: Flushing, NY

Date of Birth: 49

Date & Time:  May 11, 2021, 9:00 am

Location: NYPQ, Flushing, NY

Religion: none

Source of Information: Self

Reliability: Reliable

Source of Referral: n/a

Mode of Transport: public transportation

Chief Complaint: “I’m still having heavy periods even after my D&C” x 8 months

History of Present Illness:

49- year-old female G2P2 with a PMH of hyperlipidemia, hypertension, Type 2 Diabetes, GERD and IBS presents to the preadmission clinic one week before her scheduled Endometrial ablation procedure. Dilation and Curettage was performed September 2020 but did not decrease the rate of menstrual bleeding. Since the D&C, PT reports that the first 2 days of her menstrual cycle still present with heavy bleeding. She has to change her pad size 5 every 1.5 -2 hours to avoid leakage. Day 3 till Day 5 the bleeding tapers off and is more manageable. PT has regular monthly menstrual cycles. Last menses was April 21,2021. Most recent labs report a Hemoglobin of 10 and HbA1C 6.9.  Patient is taking Ferrous sulfate 325mg daily for her anemia. Patient admits to transient dizziness with abrupt change in position. Patient denies significant cramping, pain, dysuria, frequency, urgency, pruritus, oliguria, incontinence, shortness of breath, syncope, easy bruising, unusual bleeding or fatigue.

Past Medical History:

  • Hyperlipidemia, x1 year, well controlled, Rosuvastatin 10mg x1 day
  • Hypertension, x2 years, well controlled, Edarbyclor 40/12.5mg x1 day
  • Type 2 Diabetes, x4 years, moderately controlled, Janumet 50/500 x1 day
  • GERD and IBS, x2 years, no medication.
  • Patient denies history of Cardiovascular disease, Cancer and Smoking.
  • Denies childhood illnesses
  • Immunizations – Up to date; denies COVID vaccination
  • Mammography – June 2020, unremarkable
  • Colonoscopy and upper Endoscopy – November 2020, unremarkable

Past Surgical History:

  • Cholecystectomy – 2017, NYPQ, Queens, Flushing, NY
  • Dilation and Curettage – September 2020, NYPQ, Queens, Flushing, NY
  • Denies past injuries, blood transfusions or complications.
  • Denies history of eye surgery or hernia surgery

Medications:

  • Ferrous sulfate 325mg x 1 day – anemia
  • Janumet 50/500mg (Sitagliptin 50mg + Metformin hydrochloride 500mg) x1day – Type 2 Diabetes
  • Edarbyclor 40/12.5mg (Azilsartan medoxomil 40mg + Chlorthalidone 12.5mg) x1 day – Hypertension
  • Rosuvastatin 10mg x1 day – Hyperlipidemia
  • Denies use of herbal supplements or vitamins.
  • Denies chronic use of OTC drugs.

Allergies:

  • NKDA
  • Denies food, cat, dog and environmental allergies.

Family History:

  • Mother – alive, Hypertension, Hyperlipidemia denies other illnesses or cancer
  • Father – alive, Hypertension, Type 2 Diabetes, denies other illnesses or cancer
  • 2 Children – 23 yo male and 27yo male, both alive and healthy
  • Denies family history of allergies, cancer, cardiovascular disease, lung disease, thyroid disease, gastrointestinal disease and gallbladder disease.

Social History:

  • Mrs. MH is a married 49-year-old female living with her husband and 23 year-old son.
  • Habits – She denies smoking, drinking alcohol, and use of recreational drugs.
  • Travel – Denies recent travel.
  • Diet – Patient states she likes to eat eggs and bacon for breakfast, avoids fried food but likes to eat chicken, salads and rice for dinner.
  • Exercise – Patient admits she does not have an exercise routine.
  • Sleep – Patient denies sleeping problems.
  • Safety measures – Patient does not drive.
  • Sexual Hx – Heterosexual, monogamous, uses condom as protection. Denies history of STI.

Review of Systems:

General – Denies Fever, sudden change in weight loss, loss of appetite, generalized weakness, chills, or night sweats.

Skin, hair, nails – Denies changes in texture, pruritis, excessive dryness or sweating, pigmentations, moles/rashes or changes in hair distribution.

Head – Denies headaches, syncope, loss of consciousness, recent head trauma.

Eyes – Patient wears contact lenses but doesn’t remember her prescription. Last eye exam was one year ago. Denies history of diplopia, blurry vision, halos, lacrimation, pruritis, photophobia or loss of vision.

Ears – Patient denies deafness, discharge, tinnitus or use of hearing aids.

Nose/sinuses – Denies discharge, epistaxis, or obstruction.

Mouth/throat – Denies bleeding gums, sore tongue, sore throat, mouth ulcers, voice changes or use of dentures. Does not remember last dental exam.

Neck – Denies localized swelling/lumps or stiffness/decreased range of motion.

Breast – Patient denies breast lumps, pain, discharge, swelling or erythema.

Pulmonary system – Admits to sleeping on two medium sized pillows. Denies dyspnea, dyspnea on exertion, cough, wheezing, hemoptysis, cyanosis or paroxysmal nocturnal dyspnea.

Cardiovascular system – Patient admits her feet occasionally swell in hot weather. Admits to transient dizziness with abrupt change in position. Denies cardiovascular disease, angina, syncope, murmurs, palpations and irregular heart rate.

Gastrointestinal system – Admits to regular bowel movements daily. Denies diarrhea, nausea, vomiting, eructation, regurgitation, loss of appetite, intolerance to any food, allergies, abdominal pain, unusual flatulence, hemorrhoids, constipation, rectal bleeding or blood in stool.

Genitourinary system – Denies urinary frequency or urgency, dysuria, oliguria, polyuria, hematuria, vaginal discharge, incontinence, nocturia or flank pain.

Menstrual/Obstetrical – G2P2, no complications. Dilation and Curettage -September 2020. Denies breakthrough bleeding/spotting or vaginal discharge. Regular monthly menses with very heavy bleeding on the first two days x2 years. PT needs to change her pad size 5 every 1.5-2hrs to avoid leakage. Last menses April 21, 2021.

Nervous –Denies history of syncope, muscle weakness, seizures, sensory disturbances, ataxia, loss of strength, change in cognition / mental status / memory, or balance and coordination.

Musculoskeletal system – Denies muscle/joint pain, deformity or swelling, redness or arthritis.

Peripheral vascular system – Admits to occasional feet swelling in hot weather. Denies peripheral swelling of hands, intermittent claudication, coldness or trophic changes, varicose veins or color changes.

Hematological system – Anemia diagnosis January 2020. Denies easy bruising, bleeding, lymph node enlargement, blood transfusions, or history of DVT/PE.

Endocrine system – Denies polyuria, polydipsia, polyphagia, heat or cold intolerance, excessive sweating, hirsutism, or goiter.

Psychiatric – Denies feeling of helplessness, depression/sadness, anxiety or OCD. Denies ever seeing a mental health professional or taking any mood-altering substances. Denies thoughts of hurting self or others.

Physical Exam

NOTE: Had to limit my exam to 15minutes. Items omitted due to lack of time written in blue.

Blue = what I would have documented and performed

Pink = information provided by nurse

General:  Heavy set female, appears comfortable and relaxed with overall healthy appearance. No visible distress or labored breathing. Alert, oriented to person, place and time, responsive to verbal communication. Looks her stated age and well groomed. PT able to ambulate without assistance.

Vital Signs:

BP:   R/L Seated upright in bed: 106/70, 110/75

         R/L Supine/Standing: only performed one set due time constraint

R: 17 breathes per min, unlabored   P: 70, regular

T: 98.2 degrees F (oral) O2 Sat: 97% Room air

Height: 62 inches Weight: 155 lbs.  BMI: 28.3

Skin, hair, nails: No visible lesions, rashes, bruising, ulcers, lesions or masses on exposed arms, neck and face. Equal temperature to touch in forehead, neck, forearms and wrist. Capillary refill 2 seconds. No splinter hemorrhage, beau’s lines, white spots, pitting or clubbing. Hair coarse texture, non-brittle and equal distribution. Scalp non tender to touch and palpation. No lesions, bruising, open wounds, or seborrheic dermatitis.

Sinuses: Frontal, Ethmoid, maxillary sinuses non tender to touch or palpation.

Neck: Trachea midline. No masses, lesions, lacerations, rashes, pulsations or scars visible. Non tender to palpation. No bruits bilaterally. Non tender and non-enlarged preauricular, post auricular, occipital, superficial cervical, deep cervical, submandibular, submental and supraclavicular lymph nodes.

Thyroid: Non-tender, No palpable masses. No bruits.

Ears: No lesions, masses or trauma on external ears. Tragus and auricle non tender to palpation and manipulation.  Right and left Tympanic membrane pearly grey. No perforation, redness, bulging, masses or discharge in internal auditory canals. Cone of light at 5pm in right TM and 7pm in left TM. Cerumen present sparing but no impaction. Auditory acuity intact to whisper voice. Weber midline. Positive Rinne test, Air conduction > Bone conduction in right and left ear.

Nose: Nose symmetrical. No external masses, lesions, deformities, trauma or discharge. Nares patent bilaterally. Nasal mucosa pink and well hydrated. No deviated septum. No internal lesions, perforations or deformities. No foreign bodies.

Mouth:  

Lips bright pink, hydrated, no cyanosis, no lesion or bleeding.

Uvula at midline. No tonsillar swelling or abscesses.

Oropharynx well hydrated, No mases, lesions or deviations. Non-tender to palpation.

Mucosa dark red/pink. No mouth ulcers, masses or bleeding.

Tongue – Pink, No growths, lesions, lacerations or leukoplakia.

Gingivae Pink, moist. No lesions, masses, erythema, discharge of bleeding.

Teeth no visible dental caries, loose teeth or chipped teeth. No dentures.

Eyes: No external lesions, trauma, erythema, or masses. Sclera white, cornea clear, conjunctiva pink. No ptosis. No strabismus. No exophthalmos.

Visual acuity with contact lenses – 20/20 OS, 20/20 OD, 20/20 OU.

Visual field intact bilaterally. Extraocular movement intact. NO nystagmus. Pupils equal, round and reactive. Pupils accommodate with convergence.

Fundoscopy – Red reflex intact. No hemorrhages, AV nicking, exudates, or neovascularization OU.

Lungs:  Clear to auscultation and percussion bilaterally. Symmetric chest expansion and diaphragmatic excursion. Tactile fremitus symmetric throughout. No adventitious sounds.

Chest: Symmetric, no deformities, no trauma. Respiration unlabored on Room air, no audible wheezes. No paradoxical respiration or accessory muscle use noted. Non tender to palpation throughout. Lateral to Anterior diameter 2:1.

Heart: S1 and S2 have regular rate and rhythm. No murmurs, S3, S4 or S2 splitting. No friction rubs. Carotid pulses are 2+ bilaterally. No bruits appreciated. PMI not appreciated on exam. JVP 2cm, no pulsation or distention visible on exam. 

Abdomen: Abdomen symmetric and flat. No ascites or distention. Cholecystectomy scar in RUQ at costal margin. Normal bowel sounds in all 4 quadrants. No aortic, renal, iliac or femoral bruits. Non-tender to palpation throughout all four quadrants. Tympanic equally throughout. No hepatosplenomegaly on palpation. No CVA tenderness on exam.