H&P 3

Siddharth Shah

Physical Diagnosis (Lab)

May 10, 2022

Hospital H&P #3 – Pre-Admission Testing

Identification:
Full Name: MB

Sex: Male

Location: Flushing, Queens, NY

Date and Time: May 10, 2022 – 8:35 AM

Race: Caucasian

Informant: Self, reliable

Age: 83

Religion: Catholic

Referral Source: Self

Chief Complaint: “To have a mass in my bladder removed, and check for cancer”

History of Present Illness:

83 y/o M with PMHx of BPH, DM2, GERD, HTN, hyperlipidemia and hypothyroidism presents to pre-admission testing to be cleared for a cystoscopy with mass removal tomorrow in the patient’s bladder to check to see if the mass is cancerous. Since April patient has had trouble voiding that gradually got worse and became painful in the “bladder area”, but no radiation. At worst pain would be 10/10 and described it as “someone punching”. Patient has had issues with voiding before but has been well controlled with Finasteride but has never had pain before. The voiding with the pain made the patient go see his urologist in April, who ordered a CT scan with contrast, and a mass was discovered. Unsure if it is benign or malignant, patient urologist scheduled him to have a biopsy of the mass to rule out cancer. Patient denies fever, flank pain, dysuria, hematuria, nausea, vomiting, chest pain, palpations, and shortness of breath.

Past Medical History:

  • DM for 50 years
  • BPH for 30 years
  • hypothyroidism for 30 years
  • hyperlipidemia for 30 years
  • GERD for 10 years

Past Surgical History:

  • No PSHx

 

 

 

Medications:

  • Losartan Potassium – P0 100 once daily for HTN
  • Levothyroxine – PO 7/5 mg once daily for Hypothyroidism
  • Finasteride – PO 5mg once daily for BPH
  • Pantoprazole – 40mg BID for GERD
  • Janumet – 500mg once daily for DM2
  • No vitamins
  • No aspirin

Allergies:

  • NKDA
  • No environmental allergies
  • No allergies to food

Family History:

  • Mother: Deceased (unknown age), DM2, and CAD
  • Father: Deceased (unknown age), unsure of medical history
  • Children

Social History:

  • Alcohol:  Patient no longer drinks alcohol for the last 20 years, but used to drink about 1 glass of beer for 40 years
  • Drugs: Denies past and present use of illicit drugs
  • Smoking: Patient used to smoke one cigarette a day for two years when in high school. No longer smokes
  • Marital history: Married
  • Occupational history: Retired, used to be an accountant
  • Travel: No recent travel
  • Home situation: Lives with wife
  • Sexual history: No longer sexually active, use to be sexually active with wife, monogamous or polygamous.

 

 

 

 

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, unsure of prescription. Denies visual disturbances, double vision, photophobia. Last eye exam was in December 2021 no change to vision.
  • 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. Denies dentures.
  • Neck: Denies swelling, stiffness, or decreased range of motion.
  • Breast: Denies any lumps, nipple discharge, or pain on breast.
  • Pulmonary: Denies SOB, cough, wheezing, cyanosis, orthopnea, and PND
  • Cardiovascular: Denies chest pain, denies chest tightness, denies palpitations, 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. Last colonoscopy
  • Genitourinary: See HPI
  • 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 146/76 156/80
  Supine
Standing:

 

Pulse: 68bpm, strong & regular

Respiration: 16 breath/minute, regular rate & rhythm, unlabored

O2 Sat: 99% on room air

Height: 5’9

Wt.: 175

BMI:

Temperature: 97.0 F – oral

 

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

 

Skin: Warm, and dry. No scars seen, or rashes noted b/l on arms and legs, no tattoos, good turgor b/l.

 

Nails: No clubbing. Capillary refill <2 seconds b/l 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: Moderate amount of cerumen b/l. Symmetrical, no lesions, no masses, no trauma. No discharge. TM’s are pearly white.

 

  • 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: Good dentition, no caries noted. No loose teeth.

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.