H&P 1

Siddharth Shah

Physical Diagnosis (Lab)

March 8, 2022

Hospital H&P #1 – Internal Medicine

Identification:
Full Name: PF

Sex: Female

Location: Flushing, Queens, NY

Date and Time: March 8, 2022 – 10:15 AM

Race: African American

Informant: Self, reliable

Referral Source: Self

Chief Complaint: “My asthma is getting worse”

History of Present Illness:

PF is a 74 y/o female with PMHx of COPD, seizure, depression, arthritis, and anxiety. PF PSHx is Hysterectomy, and a “sinus operation”. PF had been admitted to the clinic because 3 weeks ago patient asthma got worse. Patient notes her asthma started to flare-up 3 weeks ago spontaneously, she took two-puff of albuterol with no relief, and it prompted her to come to ED. Patient notes nothing made the asthma worse or better and occurred spontaneously. Patient described the asthma attack 10/10 and prompted her to come to the ED, as she was coughing, wheezing, and had trouble catching her breath. She has never had an asthma exacerbation like this before. Since patient visit to the ED she has been admitted but is scared to go back home as she lives alone, and because she is worried about what happens if she has another asthma exacerbation and can’t take herself to the hospital. Patient denies fever, chest pain, palpation, abdominal pain, N/V, and urinary symptoms.

Past Medical History:

  • Asthma – “For many years”
  • Arthritis – “For many years”
  • COPD – “For many years”
  • Seizure – “For many years”
  • Depression – “For many years”
  • Anxiety – “For many years”

 

 

 

 

Past Surgical History:

  • Hysterectomy – 30 years ago
  • “Sinus operation” – “Young adult”

Medications:

  • Montelukast 10mg, PO 1 daily – For asthma
  • Hydrocortisone 25 mg, cream 2x daily – For Hemorrhoids
  • Levetiracetam 500mg, PO 2x daily – For seizure
  • Sertraline 50mg PO 1x daily – For depression
  • Omeprazole 20mg PO 1x daily – For GERD

Allergies:

  • NKDA
  • Dogs
  • Cats
  • Peaches

Family History:

  • Mother: Deceased (unknown age), unsure of medical history
  • Father: Deceased (unknown age), unsure of medical history
  • Daughter: 30 y/o with depression

Social History:

  • Alcohol:  Denies alcohol use,
  • Drugs: Denies marijuana, and cocaine
  • Smoking: Quit smoking cigarettes 10 years ago with 15-year smoking history with one pack a day.
  • Marital history: Widow
  • Occupational history: Retired
  • Home situation: Lives alone
  • Sexual history: No longer sexually active

 

 

 

 

 

 

 

Review of Systems:

  • General: Admits to night sweats, and general weakness. Denies fever, 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: Admits to blind in right eye, and weak left eye. Unsure of last eye exam
  • Ears: Denies any pain, discharge, tinnitus, or use of hearing aids.
  • Nose/Sinuses: Admits to epistaxis after cleaning nose.
  • Mouth and Throat: Admits to sore throat. Denies sore tongue, bleeding gums, voice changes, and dentures.
  • Neck: Denies swelling, stiffness, or decreased range of motion.
  • Breast: Denies any lumps, nipple discharge, or pain on right breast. Can’t recall last Mammogram
  • Pulmonary: Admits to SOB, cough, and wheezing. Denies cyanosis, orthopnea, and PND.
  • Cardiovascular: Denies chest pain, palpitations, HTN, edema/swelling, irregular rhythms, and syncope.
  • Gastrointestinal: Admits to little bit of blood on tissue paper. Denies nausea, vomiting, abdominal pain, diarrhea, change in bowel habits, and constipation.
  • Genitourinary: Admits to nocturia. Denies change in urine color, dysuria, incontinence, and urgency.
  • Sexual history: No longer sexually active, denies history of STIs.
  • Menstrual and Obstetrical: Menopausal for 20+ years.
  • Nervous: Denies LOC, weakness, loss of strength, and numbness
  • Musculoskeletal: Admits to muscle, and joint pains hands b/l. Admits to history of arthritis. Denies swelling, and deformity.
  • Peripheral Vascular: Admits to swelling of legs b/l
  • Hematologic: Denies history of anemia, blood transfusions, DVT/PE.
  • Endocrine: Denies polyuria, polyphagia, polydipsia, heat/cold intolerance.
  • Psychiatric: Admits to feeling depressed and having anxiety. Patient is seeing psychiatrist at hospital part of being admitted.

Physical:

General: Patient is well appearing, no acute distress, AOx3

Skin: No scars seen, or rashes noted b/l on arms, no tattoos

 

Vital signs:

Blood pressure: Not done as equipment was left in school after bomb threat.