History

Identifying Data:

Full Name: Ms. L

Address: Jamaica Queens, NY

Date of Birth: January 1991

Date & Time: October 30, 2018

Location: NYHQ, Flushing, NY

Religion: Christianity

Marital status: single

Source of Information: Self

Source of Referral: self

Mode of Transport:  unknown

 

Chief Complaint: “I am vomiting blood” x 1 day.

 

History of Present Illness:

27 years old African American reliable female with no PMHx present to the ED today c/o of vomiting blood for the past one day. She had a cold and cough for 2 days, along with she developed vomiting, chest and abdominal pain. She came in today because she has begun to have a bloody vomit. She had 6 episode of vomiting and every time observed streak of blood. Pt took Tylenol 650 mg every 6 hours and Pepto-Bismol 2 tbs with no relief.  Pt has never experienced this pain before and describe it as sharp, stabbing and consistent. She rates the pain 10/10 at its worse, 8/10 at its best. Pain starts at the ULQ and radiates toward the chest and lower abdominal area. Pt admits of chest pain, dyspnea, cough, nausea, vomiting, sore throat, pyrosis, abdominal pain, loss of appetite, fever. weakness/fatigue and subjectively feverish. Pt currently denies diarrhea, wheezing, hemoptysis, palpitations, irregular heartbeat, visual disturbances, and dysphagia.

Past Medical History:

Present illnesses – none

Past medical illnesses – none

Childhood illnesses – Denies illnesses.

Immunizations – Not Up to date; flu vaccine 3 years ago.

Screening tests and results  –denies all screening

 

Past Surgical History:

Denies past surgeries, transfusions or injuries.

Medications:

Maalox 500mg (Aluminum/magnesium), 1-tab for stomach acid, last dose this morning

Saline (Sodium Chloride 0.9% IV Injection Solution Viaflex )- 250 ml for osmolarity maintenance, administering right now.

Allergies:

Denies NKDA

 

Family History:

Mother – 47 alive and well

Father – 50 alive and well

Brother – 21 alive and well

Sister – 12 alive and well

Maternal/paternal grandparents – Deceased at unknown age & unknown reasons

 

Social History:

Ms. L is a single female, living with her parents. She is a part-time student and part-time home depot worker.

Habits – She drinks 4-5 glasses of beer twice a week. She denies smoking cigarettes/cigars, or illicit drug use. She drinks caffeine every day.

Travel – she recently did not travel.

Diet – She has a daily hamburger and fries’ diet, in addition to a denies consuming fruits and vegetables.

Exercise – She is not active. She sleeps well about 5-6 hours each night.

Safety measures – Admits to wearing a seat belt.

 

Review of Systems:

General – Admits of loss of appetite, generalized weakness/fatigue, fever or chills. Denies recent weight loss or gain or night sweats.

 

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

 

Head – Denies headaches, vertigo or head trauma.

 

Eyes – Denies lacrimation, pruritis, visual disturbances, photophobia. Last eye exam 2018 – does not know her visual acuity; normal pressure.

 

Ears – Denies deafness, pain, discharge, tinnitus or use of hearing aids.

 

Nose/sinuses – Denies discharge, obstruction or epistaxis.

 

Mouth/throat – admits of sore throat. Denies bleeding gums, sore tongue, mouth ulcers, voice Last dental exam 2016, normal.

 

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

 

Breast – Denies lumps, nipple discharge, or pain.

 

Pulmonary system – admits of dyspnea, cough. Denies dyspnea on exertion, wheezing, hemoptysis, cyanosis, orthopnea, or paroxysmal nocturnal dyspnea (PND).

 

Cardiovascular system – admits of chest pain. Denies HTN, irregular heartbeat, palpitations, edema/swelling of ankles or feet, syncope or known heart murmur

 

Gastrointestinal system – Admits of nausea, vomiting, pyrosis, and abdominal pain. Has regular bowel movements daily. Denies change in appetite, intolerance to specific foods, dysphagia, unusual flatulence or eructations, diarrhea, jaundice, hemorrhoids, constipation, rectal bleeding, or blood in stool.

 

Genitourinary system – Denies urinary frequency or urgency, nocturia, oliguria, polyuria, dysuria, incontinence, awakening at night to urinate or flank pain.

 

Sexual Hx – She is currently sexually active with her boyfriend. Denies history of sexually transmitted diseases and using contraceptives.

 

 

Menstrual/Obstetrical – G0P0. Menarche age 13. LMP on October 6, 2018. Admits of having 28 days interval, with duration of 6 days and uses 3 pads/ 24 hours, medium. Denies dysmenorrhea, metrorrhagia, menorrhagia, and premenstrual symptoms.

 

Nervous – Denies seizures, headache, loss of consciousness, sensory disturbances, ataxia, loss of strength, change in cognition / mental status/memory, or weakness.

 

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

 

Peripheral vascular system – Denies intermittent claudication, coldness or trophic changes, varicose veins, peripheral edema or color changes.

 

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

 

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

 

Psychiatric – Denies depression/sadness, anxiety, OCD or ever seeing a mental health professional.

 

 

Physical

 

General: 27 years old well-developed female, A/O x 3, facial features symmetric. Pt is small build, height and weight within normal range appears to be reported age, good posture, and good hygiene. Pt appears clean, well-groomed, speech clear, cooperative, and appear to be in physical distress.

Vital Signs:    BP:                              R                     L

Seated             92/50               95/56

Supine              90/52               92/55

 

R:        16/min unlabored                    P:         66, regular

 

T:        99.8 degrees F (oral)               O2 Sat: 99% Room air

 

Height 65 inches    Weight 120 lbs.    BMI: 20.0

 

• Nails: no sign of clubbing, koilonychia, paronychia. capillary refill <2 seconds throughout.
• Skin:  warm & moist and smooth to touch, good turgor. Nonicteric, no evidence of hypo or hyper pigmentation, cyanosis, erythema, mass, lesions, scars but lots of tattoos.
• Hair: average quantity, course and evenly distributed without any sign of alopecia, no nits or seborrhea noted.
• Head: normocephalic, atraumatic, no specific facies. non -tender to palpation throughout

Eyes –

Symmetrical OU; no evidence of strabismus, exophthalmos, ectropion, entropion, ptosis, edema, inflammation, crusting, discharge; Lacrimal gland does not seem enlarged and no evidence of excessive tearing or dryness of the eye . Sclera white; conjunctiva & cornea clear. No sign of cataracts

Visual acuity (uncorrected – 20/20 OS, 20/20 OD, 20/20 OU).

Visual fields is intact in all four quadrant .   PERRLA,  EOMs intact with no nystagmus

Fundoscopy – Red reflex intact OU.  Cup: Disk < 0.5 OU/no evidence of A-V nicking, papilledema, hemorrhage, exudate, cotton wool spots, or neovascularization OU.

Ears:

Symmetrical, no evidence of mass, lesion, erythema, inflammation, ear canal atresia. Non tender to palpation

Otoscopic exam: no evidence of mass, lesion, erythema, foreign bodies, discharge, inflammation or infection in external auditory canals AU. Tympanic Membrane is pearly white / intact with light reflex in the normal position.

Auditory Acuity: whisper test, intact to whispered voice AU. Weber Test midline

Rinne reveal AC> BC AU

 

Nose:

Symmetrical, no evidence of mass, lesion, deformities, erythema, inflammation or discharge. Non-tender to palpation and no step-off. no evidence of nasal obstruction

Rhinoscopic Exam: Nasal mucosa pink & well hydrated. No discharge noted on anterior rhinoscopy.  Septum midline without lesions / deformities / injection / lower and middle turbinates.   No evidence of foreign bodies.

 

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

 

Mouth & pharynx:

 

Lips –   Pink, moist; no evidence of cyanosis or lesions.   Non-tender to palpation.

Mucosa – Pink ; well hydrated.   No masses; lesions noted.   Non-tender to palpation.

No evidence of leukoplakia  or oral candiditis

Palate – Pink; well hydrated.   Palate intact with no lesions; masses; scars.  Non-tender to

            Palpation.

Teeth – Good dentition  / 4 dental caries noted.

Gingivae –Pink; moist.  No evidence of hyperplasia; masses; lesions; erythema or discharge.

       Non-tender to palpation.

Tongue – Pink; well papillated; no masses, lesions or deviation noted.   Non-tender to palpation.
Oropharynx – Well hydrated; no evidence of injection; exudate; masses; lesions; foreign bodies.

Tonsils present with no evidence of injection or exudate.  Uvula pink, no edema, lesions

 

Neck, trachea, thyroid:

Neck – Trachea midline.   No masses; lesions; scars; pulsations noted. Tender to

Palpation no thrills; bruits noted bilaterally, no palpable adenopathy noted.

Thyroid – Non-tender; no palpable masses; no thyromegaly; no bruits noted.