Identifying Data :
Full Name: Ms. GP
Address: Bayside, NY
Date of Birth: January 21, 1961
Age: 60 yo
Date & Time: March 16, 2021 9:00am
Location: NYPQ, Flushing, NY
Religion: None
Source of Information: Self
Reliability: Reliable
Source of Referral: Self
Chief Complaint : “Right-sided hip replacement and left-sided weakness.” x 1 week
History of Present Illness :
60 year old female patient with a past medical history of stroke, arthritis, cholelithiasis, and thyroid cancer presents to the ED following right-sided hip replacement and stroke. Patient received elective right hip surgery on 3/9/21, experienced a stroke on the morning of 3/10/21, and remains yet to be discharged. Patient appears mentally alert with unimpaired speech function. She states that the hip pain was sharp, radiated down her right thigh, and present for 5-6 years. The pain was exacerbated by walking, became increasingly painful with each year, and rated a 15/10. Pain was constantly present and not relieved by rest or Tylenol. Patient denied steroid injections and opted for elective hip replacement surgery instead. After surgery, patient experiences left-sided weakness and slowness, affecting her left arm and left leg. She denies pain, paresthesias, or loss of tactile function on left side of the body. Right hip after surgery presents with a dull pain, stiffness, swelling and limited range of motion. Patient is unable to walk by herself and has difficulty repositioning herself. Patient experiences nausea and constipation with 3 bowel movements in the past week. Patient also states dizziness and lightheadedness in the mornings. Denies vomiting, shortness of breath, heart palpitations, fever, visual changes, diarrhea, sweating, fainting, or loss of consciousness. Denies any recent travels.
Past Medical History
Past Surgical History
Medications
Currently On :
Previously On:
Allergies
Family History
Social History
Ms. GP is a 60 year old female and lives at home with her 63 year old husband and 27 year old son. She is a housewife and maintains a monogamous relationship.
Habits : Patient smoked 1-2 cigarettes a day for 20 years but quick after her first stroke in 2016. Her husband continues to smoke a pack a day for the past 40 years. Patient states that she makes sure her husband smokes outside of the house.
Travel : Denies recent travel. Prior to Covid-19, patient visited family in Poland every 2 years. Patient’s last trip took place in 2018.
Diet : Patient eats a whole foods diet balanced in grains, protein, vegetables, and fruit.
Exercise : Patient performs minimal to light activity. Most of her exercise comes from afternoon walks and cleaning the house.
Sexual History : Heterosexual, monogamous. States she has not been sexually active in recent years. Denies history of sexually transmitted diseases.
Review of Systems
General – Patient presents with pallor, poor grooming, weakness, and recent weight loss during 1 week hospital stay. Experiences loss of appetite and generalized weakness/fatigue. Denies fever, chills, night sweats.
Skin, hair, nails – Skin is pale, thin, and dry. Nails are brittle and pitted. Capillary refill is normal. Denies excessive dryness or sweating, discolorations, pigmentations, rashes, pruritus.
Head – Experiences lightheadedness and dizziness in the mornings. Denies headaches, vertigo, head trauma.
Eyes – Denies other visual disturbances, lacrimation, photophobia, or pruritus. No glasses/ contacts.
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 changes or use dentures. Last dental exam 2 years ago – normal.
Neck – Experiences neck stiffness and decreased range of motion. Unable to fully rotate her head. Denies localized swelling/lumps.
Breast – Denies lumps, pain, or discharge.
Pulmonary system – Denies dyspnea, dyspnea on exertion, dry cough, wheezing, hemoptysis, cyanosis, orthopnea, or paroxysmal nocturnal dyspnea (PND).
Cardiovascular system – Denies chest pain, palpitations, edema/swelling of ankles or feet, syncope
Gastrointestinal system – Experiences nausea and constipation. Patient had 3 bowel movements in the past week. Denies vomiting, intolerance to specific foods, dysphagia, pyrosis, abdominal pain, diarrhea, hemorrhoids, constipation, rectal bleeding.
Genitourinary system – Denies urinary frequency or urgency, nocturia, oliguria, polyuria, dysuria, awakening at night to urinate or flank pain.
Menstrual and Obstetrical — Menarche age 13. Last menstrual cycle took place 9 years ago, age 51. Menopause was accompanied with hot flashes and fatigue. Denies abnormal vaginal discharge color, amount, odor, or itching.
G = 2, T = 1, P = 0, A = 1, L = 1
Nervous – Denies seizures, headache, loss of consciousness, or change in mental status / memory.
Musculoskeletal System – Experiences muscle weakness and slowness on the left side of her body. Dull aching, swelling, and stiffness on the right hip. Denies redness or sharp pains.
Peripheral Vascular System – Denies coldness or trophic changes, peripheral edema, or color changes.
Hematological System – Presents with 4 – 5 1cm bilateral bruises on each arm. Denies anemia, lymph node enlargement, blood transfusions, or history of DVT/PE.
Endocrine System – Denies polyuria, polydipsia, polyphagia, heat or cold intolerance, excessive sweating or goiter
Psychiatric – Patient experiences depression/sadness for the past decade. Denies anxiety, OCD, or ever seeing a mental health professional. Not suicidal or homicidal.
Physical Exam
General: Female patient appears with pallor, poor grooming, and weak while seated.
Skin: Dry, pale, and cool to touch. Bilateral bruising of the arm with 4-5 bruises on each arm with a diameter of 1 cm.
Nails: Clean cut, pitted, and brittle. Capillary refill is normal.
Head: Skull is normocephalic. Hair is greasy, full, and of average texture.
Eyes: Sclera is white and conjunctiva is pink. Pupils are equal, round, reactive to light. Discs are sharp and flat. No hemorrhages or exudates.
Ears: External auditory canals are non-tender to touch. Presence of yellow cerumen. Tympanic membranes are intact with good cone of light. Weber test heard midline. Rinne test showed AC>BC bilaterally.
Nose: Nose and sinuses were non-tender to touch. No signs of nasal swelling or deviation.
Physical Exams Not Performed
Vitals
Blood Pressure – (R) 82/50, (L) 85/50 seated
**Patient had difficulty moving and could not obtain another position.**
Pulse Rate – 72 bpm, regular
Respiratory Rate – 20/min, unlabored
Temp – 98.9 °F (axillary)
O2 Sat – 98%
Height – 5’3”
Weight – 135 lbs
BMI – 23.9
