Final H&P

 

Siddharth Shah

Physical Diagnosis (Lab)

November 22, 2022

Hospital H&P 6 – Internal Medicine

Identification:
Full Name: PF

Sex: Male

Location: Flushing, Queens, NY

Date and Time: November 25, 2022 – 10:15 AM

Race: Hispanic

Informant: Self, reliable

Age: 65

Religion: Catholic

Referral Source: Self

Chief Complaint: “I have shortness of breath” x4 weeks

History of Present Illness:

65 y/o M with PMHx of diabetes mellitus type 2, hypertension and coronary artery diseases presented to the emergency department yesterday complaining of shortness of breath, and was admitted to internal medicine for pleural effusion. Four weeks ago, patient medication was switched by his primary care physician he can’t recall which medication was changed, and he believed the shortness of breath was due to the medication change and didn’t seek help until yesterday because his shortness of breath was still the same, it wasn’t any worse than before, but he was now worried since there was no improvement. He called his primary care physician, and was told to come to the ED, where patient was diagnosed with pleural effusion. Patient notes that movement such as walking, and climbing the stairs worsen his shortness of breath and described it as 8/10 in terms of severity, his shortness of breath was relieved by laying down or sitting. Along with his shortness of breath patient had cough but no sputum. Patient denies any prior history of pleural effusion. Patient denies chest pain, radiating pain to arms, fever, night sweats, palpations, syncope, orthopnea and diaphoresis. Patient denies taking any medication for his shortness of breath.

 

 

 

 

 

Past Medical History:

  • Coronary Artery Disease for unknown amount of years
  • Diabetes Type 2 – unknown amount of years
  • Hypertension – unknown amount of years

Past Surgical History:

  • Triple bypass 10 years ago at NYQP – no complications

Medications:

  • Metropol 50 mg 1x day
  • Bumetanide 2mg 1x day
  • Simvastatin 40mg 1 x day
  • Sacubitril-valsartan 50 mg x 1 day
  • Allopurinol 300mg 1x day
  • Metformin 1000mg 2x day
  • Clopidogrel 75mg 1x day

Allergies:

  • NKDA
  • No environmental allergies
  • No allergies to food

Family History:

  • Mother: 87 alive unaware of medical issues
  • Father: Deceased, unaware at what age, and unaware of any medical history
  • Children: 1 Daughter 32 years old with no medical history
  • Sibling:  67 brother unaware of medical history
  • Grandparents: Unaware of medical history, and what age they passed away.

Social History:

  • Alcohol:  Socially drinks at event about one beer.
  • Drugs: Denies past and present use of illicit drugs
  • Smoking: 41-year smoking history about one pack a week
  • Marital history: Never married
  • Occupational history: Retired, formerly store manager of grocery store
  • Travel: No recent travel
  • Home situation: Lives at home alone
  • Sexual history: No longer sexually active

 

Review of Systems:

  • General: Denies fever, night sweats, chills, loss of appetite, no recent changes to weight
  • Skin, Hair, and Nails: Denies change in texture, discoloration, pigmentation, moles, rashes, and pruritis.
  • Head: Denies any headaches, vertigo, LOC or lightheadedness.
  • Eyes: Patient wears corrective lenses. Denies visual disturbances, double vision, photophobia.
  • Ears: Denies any pain, discharge, tinnitus, or use of hearing aids.
  • Nose/Sinuses: Denies discharge, obstruction, or epistaxis.
  • Mouth and Throat: Denies bleeding gums, sore tongue, sore throat, mouth ulcers, voice changes or use dentures.
  • Neck: Denies swelling, stiffness, or decreased range of motion.
  • Breast: Denies any lumps, nipple discharge, or pain on breast.
  • Pulmonary: Admits to shortness of breath, and coughing, denies wheezing, sputum, orthopnea, cyanosis, and PND
  • Cardiovascular: Denies chest pain, denies chest tightness, denies irregular heartbeat, denies edema of feet, denies heart murmur, denies syncope
  • Gastrointestinal: Has regular bowel movements daily. Denies nausea, vomiting, abdominal pain, diarrhea, change in bowel habits, and constipation or any intolerance to food
  • Genitourinary: Demies Hematuria, incontinence, nocturia, urgency, oliguria, dysuria or polyuria
  • Sexual history: Denies history of STIs.
  • Nervous: Denies seizures, headaches, LOC, sensory disturbances, ataxia, loss of strength, change in mental status, or memory loss.

 

  • Musculoskeletal: Denies muscle/joint pain, swelling, weakness, changes in range of motion, redness or arthritis.

 

  • Peripheral Vascular: Denies peripheral edema, intermittent claudication, or varicose veins.
  • Hematologic: Denies history of anemia, blood transfusions, DVT/PE.
  • Endocrine: Denies polyuria, polydipsia, polyphagia, heat or cold intolerance, and excessive sweating.

 

  • Psychiatric: Denies depression/sadness, anxiety, OCD or ever seeing a mental health professional

 

Physical:

Vitals:

 

Blood pressure: Left Arm Right Arm
  Seated 113/66 mm/Hg 115/70 mm/Hg
Supine 112/68 mm/Hg 114/69 mm/Hg
Standing (Done on friend) 120/70 mm/Hg 122/73 mm/Hg

 

Pulse: 70 bpm, normal sinus rhythm

Respiration: 18 breath/minute, regular rate & rhythm, unlabored

O2 Sat: 91% on nasal cannula

Height: 5’11

Wt.: 202

BMI: 28.23

Temperature: 98.1 F – oral

 

General: Slightly overweight, well groomed, well nourished, appears stated age, A&Ox3, no acute distress, good posture,

 

Skin: Vertical chest scar from surgery 10 inches well healed, Right arm IV placement, clean no erythema or ecchymosis, and no erythema or bruising, no rashes noted bilaterally on arms and legs, no tattoos, good turgor bilaterally

 

Nails: No clubbing. Capillary refill <2 seconds bilaterally on upper, and lower extremities

 

Hair: Average quality and distribution of hair. No seborrhea upon scalp inspection.

 

Head: Normocephalic, atraumatic, nontender to palpations throughout.

 

Ears: Positive for slight cerumen b/l. Symmetrical, no lesions, no masses, no trauma. No discharge.

 

  • Auditory test:
    • Auditory acuity intact on whisper test
    • Weber is midline
    • Rinne AC>BC b/l

 

Eyes: Symmetrical OU, no strabismus, no exophthalmos, sclera is white, cornea clear, and conjunctiva is pink.

Visual Acuity Corrected: 20/20 OS, 20/20OD, 20/20 OU

Visual field: PERRL, EOM

Fundoscopy: Red reflex intact OU. Cup to disk ratio< 0.5 OU.  No AV nicking, hemorrhages, or exudates

 

Nose: No masses, lesions, trauma, discharge. Nasal mucosa pink & well hydrated. No discharge noted on anterior rhinoscopy. No foreign bodies.

 

Sinuses Non tender to palpation and percussion over bilateral frontal, ethmoid and maxillary sinuses.

 

Neck: Trachea midline, no masses, lesions, scars. Nontender to palpation. Carotid pulses are 2+ bilaterally. No cervical lymphadenopathy

Thyroid: Non-tender on palpation.

Mouth:

Lips: Pink and dry, no cyanosis or lesions. Non-tender to palpation.

Mucosa: Pink; well hydrated. No masses or lesions noted.  Non-tender to palpation. No leukoplakia.

Palate: Pink; well hydrated. Palate intact with no lesions; masses; scars.

Teeth: No teeth, no dentures.

Gingivae: Pink; moist. No hyperplasia; masses; lesions; erythema or discharge.

Tongue: Pink. No masses or lesions. Non-tender to palpation.

Oropharynx: No masses, lesions, or foreign bodies. Grade 1 tonsils, class I Mallampati. Uvula pink and midline

Chest: Symmetrical, no deformities, no trauma. Respiration is unlabored, and no use of accessory muscle noted. Lat to AP diameter 2:1. non-tender to palpation throughout.

Lungs: Clear to auscultation and percussion bilaterally. Equal chests rise and diaphragmatic excursion symmetrical. Tactile fremitus symmetric throughout. No adventitious sounds.

Heart: JVP is 2.5 cm above the sternal angle with the head of the bed at 30°. PMI in 5th ICS in mid-clavicular line.  Carotid pulses are 2+ bilaterally without bruits. Regular rate and rhythm (RRR). S1 and S2 are distinct with no murmurs, no S3 or S4.  No splitting of S2 or friction rubs appreciated.

 

Abdomen: Non-tender to palpation and tympanic throughout, no guarding or rebound noted. Abdomen flat and symmetric with no scars, striae or pulsations noted.  Bowel sounds normoactive in all four quadrants with no aortic/renal/iliac or femoral bruits. No hepatosplenomegaly to palpation, no CVA tenderness appreciated.

 

Male Genetalia and Hernias: Circumcised male. No penile discharge or lesions. No scrotal swelling or discoloration. Testes Descended bilaterally, smooth and without masses. Epididymis nontender. No inguinal or femoral hernias noted.

 

Anus, Rectum, and Prostate No perirectal lesions or fissures. External sphincter tone intact. Rectal vault without masses. Prostate smooth and non-tender with palpable median sulcus Stool brown.

Breast Exam: Breasts: Symmetric, no dimpling, no masses to palpation, nipples symmetry without discharge or lesions.  No axillary nodes palpable

 

Neurological Exam: Mental Status: Alert and oriented to person, place, and time. Receptive and expressive abilities intact. Thought coherent, no dysarthria, dysphonia, or aphasia. Memory and attention intact excluding during episode

Cranial Nerves ll – Xll intact (Did odor on friend)

  • Motor/Cerebellar: Full active/passive ROM of all upper extremities without rigidity or spasticity. Symmetric muscle bulk with good tone. No atrophy, tics, tremors, or fasciculation. Strength 5/5 throughout.  Did lower extremities on friend

Rhomberg negative, no pronator drift noted. Gait steady with no ataxia. Tandem walking and hopping show balance intact. Coordination by rapid alternating movement and point to point intact bilaterally, no asterixis (Did on friend)

  • Sensory: Intact to light touch, sharp/dull, and vibratory sense throughout.
  • Reflexes:
Biceps Triceps Brachioradialis Patellar Ankle/Achilles Babinski
Right 2+ 2+ 2+ 2+ 2+ Absent
Left 2+ 2+ 2+ 2+ 2+ Absent

 

Peripheral Vascular:  Skin normal in color and warm to touch upper and lower extremities bilaterally.  No calf tenderness bilaterally, equal in circumference.  Homan’s sign not present bilaterally. No palpable cords or varicose veins bilaterally (patient had on compression stocking machine to avoid DVT, performed on friend). No cyanosis, clubbing / edema noted bilaterally

 

Skeletal exam: No soft tissue swelling / erythema / ecchymosis / atrophy / or deformities in bilateral upper and lower extremities. Non-tender to palpation / no crepitus noted throughout. FROM (Full Range of Motion) of all upper and lower extremities bilaterally.  No evidence of spinal deformities.  (patient was tired so did lower extremity exam on friend)

 

Assessment:  65 y/o M with PMHx of diabetes mellitus type 2, hypertension and coronary artery diseases presented to the ED yesterday complaining of shortness of breath for 4 weeks.

Plan:

  • Get Pulse-ox to see how patient is breathing on room-air, and if he needs to be on nasal cannula
  • Get D-dimer as patient is shorth of breath, doesn’t exercise, history of smoking, coronary artery disease, patient doesn’t exercise, and spends most of his time at home need to rule out pulmonary embolism. D-dimer is good at ruling out pulmonary embolism as it is sensitive for blood clots.
  • Get spirometry to rule out Chronic obstructive pulmonary disease as patients have 41-year history of smoking and can develop bronchitis or emphysema. Spirometry will measure how much the patient can breathe in and out.
  • Get chest-x ray to rule out foreign body, Congestive Heart Failure, and to look for abnormal masses in lung since patient has a 41-year history of smoking, and could developed cancer.
  • Get EKG (Look for Afib, STEMI), Troponin (Will pick up if there is any heart damage) to rule out myocardial infraction.

Differential Dx:

  • Pulmonary Embolism: Patient doesn’t exercise, has 41-year history of smoking, has history of hypertension, coronary artery disease, and is diabetic. Has no chest-pain, chest tightness, and fever, this would be my number on my differential diagnosis and needs to be ruled out first. Pulmonary embolism can cause pleural effusion as well

Plan: Get D-dimer to rule out pulmonary embolism. If D-dimer is positive can get doppler of legs to look for clots.

  • Congestive Heart-Failure –  Patient main complaint is shortness of breath, no fever, no chest pain, no palpations, and given history of triple bypass surgery, coronary artery disease, hypertension, he is a at higher risk for congestive heart failure.

Plan: Get chest-x-ray to look for Kerley B-lines, and cardiomegaly, and if patient is suffering from congestive heart failure one of the symptoms of congestive heart failure is pleural effusion, and chest-x-ray will show fluid in the pleural space. Perform physical exam, looking for Juglar venous distention.

  • COPD: Patient complaint is shortness of breath for four weeks, with no other constitutional symptoms. Given his history of smoking he has a higher chance of developing COPD
    • Plan: Lung pulmonary function test will allow us to measure the amount of air patient can inhale and exhale and how much air the patient lungs can hold. Obtain a chest-x ray as well, as emphysema will show up on chest-x-ray. Can also get an Arterial Blood gas analysis, which will measure how well the patient lungs are bringing oxygen into their blood and removing carbon dioxide.
  • Lung Cancer – Lower on my differential diagnosis, but possible since patient has a 41-year history of smoking. Patient with lung cancer tend to have fever, cough with blood, and feel tired. Patient doesn’t have any of those symptoms, but it is possible patient could have early signs of lung cancer, and should be ruled out as patient has never been screened for lung cancer.
    • Plan: Get CT scan of lungs to look for any abnormal growth and if there is any, patient will be referred for bronchoscopy for a biopsy.
  • Infectious causes: This would be on bottom of my differential diagnosis as patient doesn’t have any constitutional symptoms such as fever, diaphoresis, but does have a cough. I would be concerned about COVID, viral-illness and Pneumonia.
    • Plan: Get COVID swab, RVP to check for any viral illness, and chest x-ray to rule out Pneumonia.
    • CBC count with differential to look at an increase in neutrophil count can lead us to bacterial infection, but unlikely patient has bacterial infection since the shortness of breath has been going on for four weeks with no constitutional symptoms.