Identifying Data:
Full Name: Ms. A. B
Address: Queens, NY
Date of Birth: 04/18/1966
Date & Time: 5/4/2021
Source of Information: Self
Reliability: Reliable
Source of Referral: Orthopedist
Chief Complaint: “I have a problem with my toe” for 10 years.
History of present Illness:
A 55-year-old female with PMH of osteoarthritis, asthma, HIV, and uterine fibroid presents to Preadmission Testing for her right foot surgery on 5/14. The surgery is for her osteoarthritis of the 1st MTP joint. The patient complains of right great toe pain and stiffness started10 years ago, and it’s getting worse in the past five years. The pain is described as aching, constant, and localized, with an intensity of 8/10. Pain is worse in the morning and at night before sleep. Pain can be alleviated by a muscle relaxer and made worse by walking and standing. She tries not to rely on muscle relaxer; the last dose was taken a week ago. The patient denies recent trauma, other muscle/joint pain, sensory change, fever, chills, chest pain, and SOB.
Past Medical History:
Uterine fibroid x 2 years
HIV x 11 years, CD4 count around 600, undetectable viral load (result from a month ago)
Asthma x 50 years, well controlled
Sleep apnea, resolved after gastric bypass and weight loss
Screening Test – Pap smear 2020, normal
Mammogram 2018, normal
Immunization up to date
Past Surgical History:
Cholecystectomy in 2010
Back surgery in Oct 2020
Gastric bypass in Nov 2020
Medications:
Biktarvy (bictegravir, emtricitabine, and tenofovir alafenamide) PO once daily for HIV. Last dose was taken yesterday.
Unknown muscle relaxer for toe pain. Last dose was taken a week ago.
Albuterol nebulizer (albuterol sulfate) PRN for asthma. Haven’t used it in a long time.
Allergies:
Bactrim, sulfasalazine, crab and shellfish. Denied environmental allergy
Family History:
Mother – 80, alive and well
Father – 86, alive and well
Son – 29, alive and well
Uncle (maternal side) – Deceased at age 70, throat cancer
Denied family history of diabetes, heart disease, lung disease, gastrointestinal disease
Social History:
Ms. A.B is a single women living with her mother.
Habits – 4-pack year smoking history. Drinks a glass of wine occasionally (5 ounce). Denies history of substance abuse and illicit drug use. She drinks 1 cup of coffee daily.
Travel – Denies recent travel
Occupation – Customer service at tennis center
Sleep – sleeps well after gastric bypass and weight loss
Exercise – Not active due to osteoarthritis
Sexual Hx – Patient is sexually active with one male partner for the pass 10 years. Patient doesn’t use protection. Denies history of sexually transmitted disease.
Review of Systems:
General – Ms. A.B. lost 100lb after gastric bypass. Denies loss of appetite, generalized fatigue, fever and night sweats.
Skin – Denies new moles/rashes, change of skin texture, pigmentation, excess dryness or sweating, open wound, itchiness.
Head – Denies headache, light-headedness, recent head trauma, sinus pain or nasal congestion.
Eyes – Wears bifocal glasses. Last eye exam in 2018. Denies other visual disturbances, photophobia, redness, discharge and tearing.
Ears – Denies deafness, pain, discharge, tinnitus or use of hearing aids.
Nose – Denies discharge, obstruction, epistaxis, loss of smell, recent trauma to nose, itchiness.
Mouth/throat – Last dental exam in Aug 2020, normal. Denies sore throat, bleeding gum, mouth ulcers, voice change or use of dentures.
Neck –Denies localized swelling/lumps, decreased range of motion.
Breast –Denies lumps, pain, and nipple discharge.
Pulmonary system – Denies cough, sputum, dyspnea, dyspnea on exertion, orthopnea, paroxysmal nocturnal dyspnea, wheezing, hemoptysis and cyanosis.
Cardiovascular system – Denies HTN, chest pain, palpitations, irregular heartbeat, syncope or known heart murmur.
Gastrointestinal system – Occasional diarrhea after gastric bypass. Denies loss of appetite, specific food intolerance, nausea or vomiting, abdominal pain, rectal bleeding, dysphagia, hemorrhoids and jaundice.
Genitourinary system –Denies urinary frequency, urgency, oliguria and incontinence. Sexually active with one male partner. Patient doesn’t use protection. Denies history of STI.
Menstrual/Obstetrical – Uterine fibroid is monitored using ultrasound every year. G1 P1 (NSVD X1). Menarche age 13. Menopause at age 50. Denies abnormal vaginal discharge, itching, pain of vagina.
Nervous system – Denies seizure, weakness, sensory disturbances, memory change, and ataxia.
Musculoskeletal system – Osteoarthritis of 1st MTP joint on her right foot.
Hematological system –Denies history of clots, easy bruising or bleeding, anemia, blood transfusion, lymph node enlargement.
Endocrine system –Denies polyuria, polydipsia, polyphagia, heat or cold intolerance, goiter, excessive sweating or hirsutism.
Psychiatric –Denies history of depression, anxiety, feeling of helplessness, hopelessness, lack of interest in activity, suicidal thoughts, hallucination, and obsessive/compulsive disorder.
Physical Examination:
Vitals:
BP: 114/70, sitting. 110/70 supine
Pulse: 66, regular
RR: 18/min, unlabored
HT: 5’
WT: 192lb
BMI: 37.5
Temp: 98.6 F oral
Oxygen saturation: 98% room air
General – Ms. A.B is an obese women sitting up in bed, well groomed and in gown. No signs of acute distress. Appears her stated age.
Skin – Swelling around 1st MTP joint on her right foot. Skin is warm and dry. Good turgor. Nonicteric, no tattoos noted.
Hair – average quantity and distribution
Nails – no clubbing, capillary refill <2 seconds
Head – normocephalic, atraumatic, non-tender to palpation throughout
Ear – Symmetrical and appropriate in size. No lesions, masses, trauma on external ears. No discharge or foreign bodies in external auditory canals. TM is pearly white, intact with light reflex. Weber midline/Rinne reveals AC>BC in both ears.
Sinuses – Non-tender to palpation over bilateral frontal, ethmoid and maxillary sinuses
Eyes – Symmetrical OU, No strabismus, exophthalmos or ptosis. Sclera white, cornea clear, conjunctiva pink.
Visual acuity uncorrected – 20/50 OS, 20/60 OD, 20/40 OU
Visual fields full OU. PERRLA. EOMs intact with no nystagmus
Fundoscopy – Red reflex intact OU. Cup to disk ratio < 0.5OU. No AV nicking, hemorrhages, exudates or neovascularization OU.
Neck – Trachea midline. No masses, lesions, scars, pulsations noted. Supple; non-tender to palpation. FROM; no stridor noted. 2+ Carotid pulses, no thrills. Bruits noted bilaterally, no cervical adenopathy noted.
Thyroid – Non-tender. No palpable masses, no thyromegaly, no bruits noted
Chest –Symmetrical, no deformities, no trauma. Respirations unlabored/no paradoxic respirations or use of accessory muscles noted. Lat to AP diameter 2:1. Non-tender to palpation throughout
Lungs – Clear to auscultation and percussion bilaterally. Chest expansion and diaphragmatic excursion symmetrical. Tactile fremitus symmetric throughout. No adventitious sounds.
Heart – JVP is 3 cm above the sternal angle with the head of the bed at 30°. S1 and S2 are distinct with no murmurs, S3 or S4. No splitting of S2 or friction rubs appreciated.
PMI in 5th ICS in mid-clavicular line. Carotid pulses are 2+ bilaterally without bruits. Regular rate and rhythm (RRR).
Nose – Symmetrical, no masses, lesions, deformities, trauma, or discharge. Nares patent bilaterally. Nasal mucosa pink. No foreign bodies
Lips – Pink, moist, no cyanosis or lesions.
Mucosa – Pink, well hydrated, No masses; lesions noted. Non-tender to palpation. No leukoplakia.
Palate – Pink; well hydrated. Palate intact with no lesions, masses, scars.
Teeth – Good dentition. No obvious dental caries noted.
Gingivae – Pink, moist. No hyperplasia, masses, lesions, erythema or discharge.
Tongue – Pink, well papillated. No masses, lesions or deviation.
Oropharynx – Well hydrated. No injection, exudate, masses, lesions, foreign bodies. Tonsils present with no injection or exudate. Uvula pink, no edema, lesions.
