History

 Identifying Data:

Full Name: Ms. P

Address:  Jamaica Queens, NY

Date of Birth: December 20, 1955

Date & Time: April 9, 2019

Location: NYHQ, Flushing, NY

Religion: Christianity

Nationality: African American

Marital status: Married

Source of Information: Self

Source of Referral: Sonia Punj

Mode of Transport:  bus

 

Chief Complaint: “I am here for clearance for right knee replacement x 6 months

 

History of Present Illness:

63 years old reliable female with PMHx of HTN, hyperlipidemia, osteoporosis, osteoarthritis, and HIV present to the PAT for clearance for right knee replacement X 6 months. Pt was experiencing pain in her knees for years but eight months ago the pain became intolerable, as she describes the experience as stiffness, pinching, grating, throbbing pain with movement, and loss of flexibility. She rates the pain 9/10 at its worse, 4/10 at its best. Laying down and relaxation alleviate the pain, but it worsens with movement like walking, sitting or any exertion. Pt takes 2 Tylenol tablets 500 mg every 6 hours to reduce the pain and avoid movement as that aggravate the pain. The pain caused the pt to reach out to her PCP eight months ago and MRI was performed, which revealed pt need total knee replacement on both knees. Pt did her left knee replacement six month ago without any complication but could not do the right knee right away due to high blood pressure.  Pt admits of osteoarthritis, joint pain, crepitus and pain worsening with use. Pt denies dyspnea, dyspnea on exertion, wheezing, cough, chest pain, palpitation, weakness/fatigue, dysphagia, pyrosis, visual disturbances, polyuria, syncope, fever, chills, night sweats, edema of ankles and feet.

Past Medical History:

Present illnesses – HTN, hyperlipidemia, osteoporosis, osteoarthritis, and HIV

Past medical illnesses – none

Childhood illnesses – chicken pox

Immunizations –up to date; flu vaccine 7 months ago

Screening tests and results – colonoscopy- March 2018 – result unremarkable, Pap-smear- unknown, mammogram- 3 months ago- results unremarkable

 

Past Surgical History:

salpingectomy – years ago, Queens Hospital. Due to multiple ectopic pregnancies, no complications.

Left knee arthroplasty- 6 months ago, NYHQ, Flushing, NY. Due to osteoarthritis, no complications.

Denies transfusions or injuries.

 

Medications:

Amlodipine 10mg (Norvasc), 1 tb PO daily, for BP<110, last dose this morning

Benazepril 40mg (Lotensin) 1 tb PO daily, for BP<110, last dose this morning

Atorvastatin 30mg (Lipitor), 1 tb PO daily, for high cholesterol, last dose last night

Ezetimibe 10mg ( Zetia), 1-tab PO daily, for  cholesterol, last dose this morning

DESCOVY 200-25 mg, 1-tab PO daily, for  HIV, last dose this morning

Efavirenz 600 mg (Sustiva), 1-tab PO daily, for  HIV, last dose this morning

centrum silver multivitamin supplement 1-tab PO daily, last dose this morning

 

Allergies:

Penicillin- severe rash

 

Family History:

Mother – Deceased at age 70, natural cause

Father –85 alive with HTN

Brother-– Deceased at age 62- unknown cause

Brother- – Deceased at age 59- Heart Problem

Sister – 55 alive and unknown diseases

Son- 40 alive and healthy

Son- 41 alive and healthy

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

 

Social History:

Ms. M is a married female, living with her husband in a private house in Jamaica. She is a retired high school computer technician.

Habits – Admits of smoking in the past and has a 7.5 pack years but quit smoking 30 years ago Denies drinking alcohol, or illicit drug use. She drinks coffee every day.

Travel – she recently did not travel.

Diet – She has a daily fish and meat diet, in addition to a admits of not consuming fruits and vegetables.

Exercise – She is not active. She does sleep well, only 6-8 hours each night.

Safety measures – Admits to wearing a seat belt.

 

Review of Systems:

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

 

Skin, hair, nails – Denies changes in texture, excessive dryness, 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 December 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 –Denies bleeding gums, sore tongue, sore throat, mouth ulcers, voice change or dentures. Last dental- unknown

 

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

 

Breast – Denies lumps, nipple discharge, or pain.

 

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

 

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

 

Gastrointestinal system – Admits of intolerance to spicy. Has regular bowel movements in every other day. Denies change in appetite, nausea and vomiting, abdominal pain, dysphagia, pyrosis, flatulence, eructation, constipation, diarrhea, jaundice, hemorrhoids, rectal bleeding, or blood in stool.

 

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

 

Sexual Hx – She is currently sexually active with her husband. Admits of human immunodeficiency virus since 1988. Admits of using contraceptive for protection.

 

Menstrual/Obstetrical – G5-P2-0-3-2. Menarche age 14. LMP 12 years ago. Denies breakthrough symptoms or any other unwanted symptoms.

 

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

 

Musculoskeletal system – admits of joint pain and arthritis. Denies muscle pain, deformity or swelling, redness.

 

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

 

Vital Signs:     BP:                              R                     L

Seated             142/84             144/80

Supine             142/82             142/80

 

R:        16/min unlabored                    P:         75, irregular

 

T:        97.6 degrees F (oral)               O2 Sat: 98% Room air

 

Height 62 inches    Weight 200 lbs.    BMI: 36.6

 

• Nails: no sign of clubbing, cyanosis, koilonychia, paronychia. capillary refill <2 seconds throughout.
• Skin: warm & moist and smooth to touch, good turgor. Nonicteric, no evidence of hypo or hyper pigmentation, erythema, mass, lesions, scars or tattoos.
• Hair: good 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, no evidence of excessive tearing or dryness of the eye. Sclera white; conjunctiva & cornea clear. No sign of cataracts

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

Visual fields are 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 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

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

Non-tender to palpation.

Tongue – Pink; no evidence of 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.

 

THORAX & LUNGS:

 

Chest –      Symmetrical chest wall movement, no evidence of deformities, kyphosis, scoliosis, masses, lesions, cyanosis. no evidence of trauma.   Respirations rate normal and unlabored  with no paradoxic respirations or use of accessory muscles noted.  Lat to AP diameter 2:1 no evidence of barrel chest.   Non-tender to palpation.

 

Lungs –   Clear to auscultation and percussion bilaterally.   Chest expansion and diaphragmatic excursion symmetrical.   Tactile fremitus intact throughout.  No adventitious sounds.

 

Heart:  JVP is 2.5 cm above the sternal angle with the head of the bed at 30°. PMI in 5^th ICS in the mid-clavicular line.  Carotid pulses are 2+ bilaterally without bruits, regular rate and rhythm (RRR); resonance with percussion. S1 and S2 are normal. There are no murmurs, S3, S4, splitting of heart sounds, friction rubs or other extra sounds.

 

Abdomen: Flat/symmetrical/ no evidence of scars, striae, caput medusae or abnormal pulsations. BS present in all 4 quadrants.   No bruits noted over aortic/renal/iliac/femoral arteries.

Tympany to percussion throughout. Non-tender to percussion or to light/deep palpation.   No evidence of organomegaly. No masses noted.   No evidence of guarding or rebounds tenderness.   No CVAT noted bilaterally.

 

Breasts: symmetric, no dimpling, no masses, nipples without discharge.  No axillary nodes palpable

 

FEMALE GENITALIA:

External – normal pubic hair pattern, no erythema, inflammation, ulcerations, lesions or

discharge noted. BUS wnl. [BUS = Bartholins, Urethra, Skenes glands]

Vaginal mucosa without inflammation, erythema or discharge.

Cervix nulli/multiparous without lesions or discharge. No cervical motion tenderness.

Uterus retro-flexed, mobile, non-tender and of normal size, shape, and consistency.

Adnexa without masses or tenderness.

RECTAL:

No external hemorrhoids, skin tags, ulcers, sinus tracts, anal fissures, inflammation or excoriations. Good anal sphincter tone. No masses or tenderness. Trace brown stool present in vault. FOB negative.

 

Peripheral Vascular: The upper and lower extremities are normal in color, size and temperature. Pulses are 2+ bilaterally in upper and lower extremities. No bruits noted. No clubbing, cyanosis or edema noted bilaterally (no C/C/E  B/L) No stasis changes or ulcerations noted.

 

Musculoskeletal system: No soft tissue swelling / erythema / ecchymosis / atrophy / or deformities in bilateral upper and lower extremities. Non-tender to palpation / crepitus noted on right knee. FROM (Full Range of Motion) of all upper and lower extremities bilaterally except limited ROM in right knee.  No evidence of spinal deformities.

 

Mental status:

Alert and oriented to person, place and time. Memory and attention intact. Receptive and expressive abilities intact. Thought coherent. No dysarthria, dysphonia or aphasia noted.

 

Cranial Nerves

I – Intact no anosmia.

II- VA 20/20 bilaterally. Visual fields by confrontation full. Fundoscopic + red light reflex OS/OD, discs yellow with sharp margins. No AV nicking, hemorrhages or papilledema noted.

III-IV-VI- PERRLA, EOM intact without nystagmus.

V- Facial sensation intact, strength good. Corneal reflex intact bilaterally.

VII- Facial movements symmetrical and without weakness.

VIII- Hearing grossly intact to whispered voice bilaterally. Weber midline. Rinne AC>BC.

IX-X-XII- Swallowing and gag reflex intact. Uvula elevates midline. Tongue movement intact.

XI- Shoulder shrug intact. Sternocleidomastoid and trapezius muscles strong.

 

Assessment:

63 years old reliable female with PMHx of HTN, hyperlipidemia, Osteoporosis, osteoarthritis, and HIV present to the PAT for clearance for right knee replacement X 6 months result consistent with osteoarthrosis in right knee in the need of right knee replacement.

 

5      differential diagnosis

 

1. Osteoarthritis: the patient is over 60 years with chronic pain and stiffness, decreased range of motion, crepitus. Pain aggravated by weight-bearing activity and relieved by rest.
2. Rheumatoid arthritis- joint pain, stiffness, tenderness, limited range of motion but no evidence of joint erythema, swelling, effusion, warmth, fatigue, fever, or anemia.
3. Septic arthritis- the patient is immunodeficient, with severe pain and limited range of motion but no evidence of chills, fever, erythema, swelling, or warmth.
4. Chondromalacia patellae – Pain aggravated by activity such as walking, running, climbing but theater sign is negative meaning patient do not reveal extra pain with prolonged setting with knee bent. No evidence of patella apprehension pain.
5. Crystal-induced inflammatory arthropathy: severe pain and stiffness in the knee joint but no evidence of swelling, redness or fever.

 

Plan:

1. 1. Osteoarthritis – pt is clear to proceed for the knee replacement surgery on April 19, 2019. Pt is advised to discontinue the amlodipine and benazepril 1 day before the procedures.
   2. HTN- Continue amlodipine, and benazepril current dose to control blood pressure
   3. Hyperlipidemia- continue Ezetimibe and Atorvastatin current dote to control cholesterol.
   4. HIV- Continue the DESCOVY and Efavirenz at a current dose to control the HIV

Problem list:

1. HIV
2. HTN
3. Osteoporosis
4. Osteoarthritis
5. Hyperlipidemia