Identifying Data :
Full Name: Ms. MA
Address: Flushing, NY
Date of Birth: March 12, 1942
Age: 79 yo
Date & Time: April 27, 2021 9:30am
Location: NYPQ, Flushing, NY
Religion: None
Source of Information: Self
Reliability: Reliable
Source of Referral: Primary Care Physician
Chief Complaint : “Surgery for left knee pain.” x2 years
History of Present Illness :
79 year old female patient with a past medical history of osteoarthritis, hypertension, and endometrial cancer presents to the ED for a scheduled left knee replacement surgery. Patient has experienced sharp left knee pain for the past two years that is exacerbated upon ambulation. Patient is able to walk for 30 minutes before experiencing significant discomfort and needing to sit down. The pain is rated a 8/10, constant, radiates up her left thigh, and accompanied by stiffness in the morning and after sitting for too long. Patient denies trauma or falls to the affected area. In the past, patient experienced similar symptoms in her right knee and had a total knee placement in 2010. She currently takes Celecoxib 100 mg twice daily, but continues to experience significant pain in the left knee. Patient denies numbness or weakness in the the legs. Denies dizziness, loss of consciousness, palpations, chest pain, shortness of breath, nausea, vomiting, constipation, diarrhea, fever. Denies recent travels.
Past Medical History
Past Surgical History
Medications
Currently On :
Allergies
Family History
Social History
Ms. MA is an 79 year old female and lives at home alone. Patient was a homemaker. Her husband passed away seven years ago and her children live out of state. For the past month, her niece has been living with her due to her worsening knee pain. Her niece will be her primary caretaker after the surgery.
Habits : Patient denies use of alcohol, smoking, or recreational drugs.
Travel : Denies recent travel.
Diet : Patient eats a whole foods diet of home-cooked meals balanced in grains, protein, vegetables, and fruit.
Exercise : Patient maintains a relatively sedentary lifestyle due to worsening knee pain. However, she tries to go for walks as tolerated.
Sexual History : Heterosexual, husband is deceased. States she has not been sexually active in over a decade. Denies history of sexually transmitted diseases.
Review of Systems
General – Patient appears well-groomed, well-nourished, and mentally alert while seated. Denies loss of appetite, generalized weakness/fatigue, fever, chills, night sweats.
Skin, hair, nails – Denies excessive dryness or sweating, discolorations, pigmentations, moles, rashes, pruritus.
Head – Denies headaches, vertigo, head trauma, coma, or fractures.
Eyes – Patient experiences dry eyes and takes eye drops. Denies other visual disturbances, lacrimation, photophobia, or pruritus. Wears reading glasses. Last eye exam was 2 year ago.
Ears – Denies deafness, pain, discharge, tinnitus, or use of hearing aids.
Nose/sinuses – Denies discharge, obstruction, or epistaxis.
Mouth/throat – Uses full set of dentures. Denies bleeding gums, sore tongue, sore throat, mouth ulcers, voice changes. Last dental exam 1 year ago – normal.
Neck – Denies localized swelling/lumps. Denies stiffness or decreased range of motion.
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 – Denies nausea, vomiting, diarrhea, or constipation. Denies 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 12. Last menstrual cycle took place 28 years ago, aged 52. Menopause was accompanied with hot flashes and fatigue. Denies abnormal vaginal discharge color, amount, odor, or itching.
G = 6, T = 4, P = 0, A = 2, L = 4
Nervous – Denies seizures, headache, loss of consciousness, or change in mental status / memory.
Musculoskeletal System – Sharp pain and stiffness of left knee that radiates up left thigh. Denies muscle weakness and slowness. Denies aching, swelling, or redness.
Peripheral Vascular System – Denies coldness or trophic changes, peripheral edema, or color changes.
Hematological System – Received blood transfusion during 2012 hysterectomy. Denies anemia, echymosis, lymph node enlargement, history of DVT/PE.
Endocrine System – Denies polyuria, polydipsia, polyphagia, heat or cold intolerance, excessive sweating or goiter.
Psychiatric – Denies depression, anxiety, OCD, or ever seeing a mental health professional. Not suicidal or homicidal.
Vitals
Blood Pressure
(R) 151/93 (L) 155/80 seated
(R) 150/90 (L) 150/85 supine
Pulse Rate – 80 bpm, regular
Respiratory Rate – 20/min, unlabored
Temp – 97.8 °F (axillary)
O2 Sat – 98% room air
Height – 5’
Weight – 184 lbs
BMI – 35.9
Physical Exam
General: Female patient appears alert, well-groomed, well-nourished, while seated. Patient does not appear to be in respiratory or cardiac distress.
Skin: Warm and moist with good turgor. Non-icteric, no lesions, masses, scars, tattoos, or bruising.
Nails: Clean cut. Capillary refill is normal and <2 seconds throughout. No clubbing, splinter hemorrhages, beta lines, koiconychia, or paronychia.
Head: Skull is normocephalic and non-tender to palpation. Hair is full, average texture, and good luster.
Eyes: Sclera is white and conjunctiva is pink. Pupils are equal, round, reactive to light. EOMs are full with no nystagmus or strabismus.
Visual Acuity : Corrected – 20/20 OS, 20/20 OD, 20/20 OU
Fundoscopy : Red reflex is present. Cup:Disk <0.5 OU. No AV nicking, papilledema, hemorrhage, exudate, cotton wool spots, or neovascularization OU.
Ears: External auditory canals are non-tender to touch. Presence of yellow cerumen. Tympanic membranes are intact with good cone of light. Whisper test presents diminished hearing bilaterally. Weber test heard midline with no materialization. Rinne test showed AC>BC bilaterally.
Nose: Nose and sinuses were non-tender to palpation. No signs of nasal swelling or deviation.
Lips: Pink, moist. No cyanosis, masses, lesions, swelling, or fissures.
Mucosa: Pink, well hydrated. No masses lesions noted. No leukoplakia. No thrush.
Palate: Pink, well hydrated. No lesions, masses, scars.
Teeth: Full set of dentures.
Gingivae: Pink, moist. No hyperplasia, recession, masses, lesions, erythema or discharge.
Tongue: Pink, well papillated. No masses, lesions, or deviation.
Oropharynx: Well hydrated. No exudate, masses, lesions, foreign bodies. Tonsils present with no injection or exudate, Grade 0. Uvula pink, no edema.
Neck – Trachea midline. No masses, lesions, scars, pulsations noted. Supple, non-tender to palpation. Good range of motion. No cervical adenopathy noted. Lymph nodes are mobile, discrete, and non-tender to palpation.
Thyroid – Non-tender to palpation. No palpable masses or thyromegaly.
Chest: Symmetrical. No deformities or trauma. Respirations are unlabored. No paradoxic respirations or use of accessory muscles. Lateral to AP diameter 2:1. Non-tender to palpation throughout.
Respiratory: Clear to auscultation and percussion bilateral. Chest expansion and diaphragmatic excursion symmetrical. Tactile remits symmetric throughout. No adventitious sounds.
Cardiovascular: JVP is 2 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, S3 or S4. No splitting of S2 or friction rubs appreciated.
Abdominal: Large scar, about 8 inches in length, present in midline of the lower abdomen from past hysterectomy. Abdomen is round with no striae or pulsations. Non-tender to palpation and tympanic throughout, no guarding or rebound noted. Tympanic throughout, no hepatosplenomegaly to palpation. Bowel sounds normoactive in all four quadrants. No CVA tenderness.
Physical Exams Not Performed
