I used to work as a Medical Assistant in an ophthalmology office. I had experience with documenting the patient’s chief complaint, past medical history, family history, and medication. At that time, my main job was to ask a similar set of questions to almost all the patients and record their answers. I didn’t need to start formulating differential diagnoses during the interview process and I didn’t know what pertinent positives and negatives to ask for. These are the skills I learned during the clinical correlation class.

At the beginning of this course, I found it difficult to ask meaningful/useful questions and elicit the right HPI.  With more practice during this class, I become more organized at interviewing and gathering relevant information. As we gain more medical knowledge throughout the semesters, I feel more confident at developing a list of differentials and I can use these differentials to guide the interview, ask more targeted questions, and order diagnostic tests. These skills will be very important for my clinical rotations. Independent research and presentation skills are also emphasized in this course. I am more comfortable using resources like UpToDate and AccessMedicine.

During the clinical year, I need to continue to work on formulating a good list of differential. I also need to improve on developing a treatment plan. The patient might have multiple conditions but come in with only one complaint. Therefore, it’s important to not get tunnel-visioned and need to provide care in a holistic approach.

• What differences do you note between the two H&Ps?

The last HPI is more concise compared to the first one.  The last H&P has a more detailed family history and social history. In the first H&P, the patient’s complaints from HPI are noted again in ROS. There is less repeating information on the third H&P.

• In what ways has your history taking improved? Are you eliciting all the important information?

On my first hospital visit, I brought a checklist with me to remind myself about all the information I should obtain from the patient.  I still brought the list with me, but I found myself relying less on the list as we got more practice on hospital patients and during clinical correlation. I get more comfortable eliciting OLDCARTS components during HPI, asking PMH, surgical history, medications, family, and social history. I have become more familiar with each category of ROS. I need to keep in mind to always ask about patients’ reactions when they report an allergy. Also, there are more pertinent positives and negatives that I could have asked.

• In what ways has writing an HPI improved?

It took me less time to write an HPI. For the first HPI, I spent a lot of time organizing all the information into a paragraph. It becomes easier because the first one can be used as a template.

• What is your self-assessment of your current skill in performing a physical exam? Which areas do you feel strongest about/weakest about?

I am comfortable performing general inspection, skin, hair, nails, head, ear, sinuses, neck, part of the eye, chest and lung exams. I need more practice on heart exams, especially about identifying and describing murmurs. I also need to get more familiar with neuro exams since there are a lot of steps. I feel the weakest about fundoscopy. I practiced on patients and on family members; I can’t really see anything besides red reflex.

• Which of the specific areas will you target as needing particular focus in future patient visits when you start the clinical year?

I need to ask the patient’s reaction to an allergen and try to rely less on the checklist for ROS. I would focus more on the physical exams that I am not too comfortable with; I need to practice more so I can perform a full physical exam in a coherent way.

Identifying Data:

Full Name: Mrs. B.D

Address: Elmhurst, NY

Date of Birth: 09/29/1952

Date & Time: 11/16/2021

Source of Information: Self

Reliability: Reliable

Source of Referral: Orthopedist

Chief Complaint: “My right shoulder hurts” x 1 year.

History of Present Illness:

A 69-year-old female with PMH of hypertension, diabetes, and hypercholesterolemia presented to Preadmission Testing for her right total shoulder replacement scheduled on 12/02/2021. The patient complained of right shoulder pain for the past year. The pain started after she tripped and fell on her right side at work a year ago, and it had not gotten better since then. The patient described the pain as dull, constant, radiating down the anterior surface of her arm at an intensity of 2/10. The intensity increased to 10/10 when she raised her right arm. The pain is alleviated by rest and exacerbated by any movements of the right shoulder. The patient tried physical therapy in the past year but it didn’t help. The patient denied syncope or loss of consciousness before/after the fall. She denied other muscle/joint pain, sensory changes, fever, chills, chest pain, and SOB.

Past Medical History:

COVID in March, 2020

Varicose vein x 5 years

Diabetes x 10 years

Hypertension x 20 years

Hypercholesterolemia x 20 years

Screening Test – Fecal occult blood test 2018, normal

Immunization up to date

Past Surgical History:

No past surgical history

Medications:

Lipitor (Atorvastatin) 10 mg PO once daily

Cozaar (Losartan) 50 mg PO once daily

Biguanides (Metformin) 500mg PO BID

Allergies

NKDA

Denied food and environmental allergies

Family History:

Mother – Deceased at age 45, heart attack.

Father – Deceased at age 69, heart attack.

Brother – 58, alive, PMH of diabetes, hypertension, and hypercholesterolemia

Daughter – 48, alive and well

Son – 44, alive and well

Social History

Mrs. B.D. is a married female living with her husband

Habits – Denies alcohol and tobacco use. Denies history of substance abuse and illicit substance use. She drinks a cup of coffee occasionally.

Travel – Denies recent travel.

Occupation – Hotel Housekeeper

Sexual Hx – Not sexually active. Menopause at age 48. Denies history of sexually transmitted disease.

Review of System:

General – Denied loss of appetite, generalized fatigue, recent weight loss or gain, fever, and night sweats

Skin – Denied moles/rashes, change of skin texture, pigmentation, excess dryness or sweating, open wound, itchiness.

Head – Denied headache, light-headedness, recent head trauma, sinus pain or nasal congestion.

Eyes – Patient is presbyopic, wears reading glasses. Last eye exam 5 years ago. Denied other visual disturbances, photophobia, redness, discharge and tearing.

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

Nose – Denied discharge, obstruction, epistaxis, loss of smell, recent trauma to nose, itchiness.

Mouth/throat – Patient has removeable dentures. Denied sore throat, bleeding gum, mouth ulcers, voice change.

Breast – Denied pain, and nipple discharge.

Pulmonary system – Denied cough, sputum, dyspnea, dyspnea on exertion, orthopnea, paroxysmal nocturnal dyspnea, wheezing, hemoptysis and cyanosis.

Cardiovascular system – Hypercholesterolemia. Denied heart murmur, chest pain, palpitations, irregular heartbeat, syncope or known heart murmur.

Gastrointestinal system – Denied Nausea, loss of appetite, abdominal pain, and watery diarrhea. Denied vomiting, rectal bleeding, dysphagia, hemorrhoids and jaundice.

Genitourinary system –Denied urinary frequency, urgency, oliguria and incontinence. Monogamous, not sexually active. Denies history of STI.

Menstrual/Obstetrical – G2 P2 (NSVD X2). Menarche age 12. Menopause at age 48. Denied abnormal vaginal discharge, itching, pain of vagina.

Nervous system – Denied seizure, weakness, sensory disturbances, memory change, and ataxia.

Musculoskeletal system – Right shoulder pain. Bilateral varicose veins. Denied back pain.

Hematological system – Denied easy bruising or bleeding, anemia, blood transfusion, lymph node enlargement.

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

Psychiatric –Denied history of depression, anxiety, feeling of helplessness, hopelessness, lack of interest in activity, suicidal thoughts, hallucination, and obsessive/compulsive disorder.

Physical Examination:

Vitals:

Temp: 98.6 F

BP: 110/70 sitting up

       120/80 supine

Pulse: 80, regular

RR: 18/min, unlabored

O2: 98% room air

Ht: 5’2’’

Wt: 140lb

BMI: 25.6

General: Average-built female in gown, sitting supine with her left hand supporting her right elbow. Patient was not in acute distress and is alert and oriented.

Skin – intact, feet are cold to palpate. No pitting edema. No jaundice.

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 fields full OU. PERRLA. EOMs intact with no nystagmus

Visual acuity corrected – 20/20 OS, 20/20 OD, 20/20 OU

Fundoscopy – Red reflex intact OU. Cup to disk ratio < 0.5OU. No AV nicking, hemorrhages, exudates or neovascularization OU.

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 – Carotid pulses are 2+ bilaterally without bruits. Regular rate and rhythm. S1 and S2 are distinct with no murmurs, S3 or S4. No splitting of S2 or friction rubs appreciated.

 JVP is 3cm above the sternal angle with the head of bed at 30 degrees.

Motor/Cerebellar – Limited active and passive ROM of right shoulder due to pain. Right arm strength 3/5. Other extremities strength 5/5. Full active/passive ROM of other joints without rigidity or spasticity. Symmetric muscle bulk with good tone. No atrophy, tics, tremors or fasciculation. Unable hold arm at 90 degree to perform Rhomerg and pronator drift.

Gait steady with no ataxia. Tandem walking and hopping show balance intact. Coordination by rapid alternating movement and point to point intact bilaterally, no asterixis

Peripheral Vascular – Varicose veins bilaterally. Feet are cold to palpation. The extremities are normal in color and size. Pulses are 2+ bilaterally in upper and lower extremities. No bruits noted. No clubbing or edema noted bilaterally. No ulcerations noted.

Musculoskeletal – Limited range of motion in right shoulder upon adduction, abduction, internal and external rotation due to pain. FROM of left shoulder and lower extremities bilaterally. No soft tissue swelling/ erythema /ecchymosis/ atrophy/ or deformities in bilateral upper and lower extremities. Non-tender to palpation/ no crepitus noted throughout. No evidence of spinal deformities.

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.

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

Abdomen – Flat and symmetric with no scars, striae, or pulsations noted. Bowel sounds normoactive in all four quadrants with no aortic/renal/iliac or femoral bruits. Non-tender to palpation and tympanic throughout, no guarding or rebound noted. Tympanic throughout, no hepatosplenomegaly to palpation, no CVA tenderness

Genitalia – External genitalia without erythema or lesions. Vaginal mucosa pink without inflammation, erythema or discharge. Cervix parous (or multiparous), pink, and without lesions or discharge. No cervical motion tenderness. Uterus anterior, midline, smooth, non-tender and not enlarged. No adnexal tenderness or masses noted. Pap smear obtained. No inguinal adenopathy.

Rectal – Rectovaginal wall intact. 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.

Breast – Symmetric, no dimpling, no masses to palpation, nipples symmetric without discharge or lesions. No axillary node palpable

Sensory – Cranial nerves I – XII intact. Intact to light touch, sharp/dull, and vibratory sense throughout. Proprioception, point localization, extinction, stereognosis, and graphesthesia intact bilaterally

Reflexes – 2+ throughout, negative Babinski, no clonus appreciated

Meningeal Signs – No nuchal rigidity noted. Brudzinski’s and Kernig’s signs negative

Differential diagnoses:

#1. Shoulder osteoarthritis: Patient’s age and previous history of injury put her at higher risk of osteoarthritis of the shoulder. Limited range of motion at the injured shoulder, constant pain, and minimal improvement with physical therapy are consistent with osteoarthritis.

#2. Rotator cuff injury: Patient’s history of falling on her right side, limited ROM of right shoulder, and pain with passive and active shoulder movement suggest rotator cuff injury. However, the patient denied pain on palpation, making this diagnosis less likely.

#3. Tendon rupture: Tendon rupture could be a result of her fall. It can cause pain and decreased range of motion at the affected joint.

#4. Shoulder bursitis: Shoulder bursitis causes shoulder pain and stiffness. Falling on her right side could cause injury to the shoulder and lead to tendinitis.

#5. Rheumatoid arthritis: The patient’s age put her at increased risk for rheumatoid arthritis. Limited range of motion and pain with joint movement is consistent with rheumatoid arthritis. However, she didn’t report any stiffness with other joints. There is no swelling for inflammation of the joint throughout.

Assessment:

A 69-year-old female with PMH of hypertension, diabetes, and hypercholesterolemia presented to Preadmission Testing for her right total shoulder replacement scheduled on 12/02/2021. The history of fall, the long duration of pain, and the symptom of pain during movement is most consistent with osteoarthritis of the shoulder.

Plan:

1. Pain control: Acetaminophen 650mg every 6 hours as needed
2. Activity: Perform range-of-motion exercises as tolerated
3. Right total shoulder replacement on 12/02/2021