History & Physical

H&P #1:

History 

Identifying Data: 

Full Name – JG

Sex – Male

Date of Birth – 1977

Date & Time – 4/14/21, 4:36 

Location – STATcare, Hicksville  

Race – Hispanic

Source of Information – Self, Reliable 

Source of Referral – Self 

Chief Complaint: Right lower back pain x2 hours

History of Present Illness: 

43 y/o male with a pmh of HTN and T2DM presents to the clinic c/o right lower back pain x2 hours. Patient states he finished his lunch and then felt the pain in his lower back. Patient has a history of kidney stones, 2-3 episodes, and states this pain feels like past episodes. Pt states pain is colicky in nature, doesn’t radiate, is 3/10 right now and is constant. Pt took Ibuprofen but his symptoms were not alleviated. pt denies any alleviating or exacerbating factors. pt admits to a tight feeling in his abdomen and urinary urgency. Pt denies nausea, vomiting, dizziness, HA, fever, abdominal pain, chest pain or other acute symptoms.

Past Medical History: 

Present Illnesses –

  • Hypertension
  • Type 2 Diabetes Mellitus

Past illnesses

  • N/A

Childhood illnesses

  • N/A

Immunizations – up to date, last flu shot – last year

Screenings –

  • Colonoscopy 2017 – normal
  • Prostate exam 2019 – normal

Pt denies past surgeries, injuries or transfusions.

Medications: 

  • Metoprolol Succinate 25 mg capsule –  ER 24 hour sprinkle 1 capsule orally once a day
  • Metformin HCl 500 mg tablet – 1 tablet with meals orally twice a day
  • Lisinopril 10 mg tablet – 1 tablet orally once a day

Allergies:

  • NKDFSA

Family History: 

Mother – deceased, diabetes

Father – alive, diabetes

Social History: 

JG is a married male, lives with his wife.

Habits – Pt admits to socially drinking 1/wk, denies smoking or other illicit drug use.

Travel – none 

Diet – attempts at eating healthy 

Exercise – once/week running

Safety measures – admits to wearing a seat belt 

Sleep – around 5 hours a night

Review of Systems 

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

Skin, Hair, Nails – Denies changes in texture, excessive dryness or sweating, discolorations, pigmentations, moles/rashes, pruritus or change in hair distribution. 

Head – Denies headache, vertigo, head trauma, unconsciousness, coma or fracture.

Eyes – Denies contacts, glasses, visual disturbances, fatigue, lacrimation, photophobia or pruritus. Pt doesn’t know when her last eye exam was. 

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

Nose/Sinuses – Denies discharge, epistaxis or obstruction. 

Mouth and Throat – Denies bleeding gums, sore throat, sore tongue, mouth ulcers, voice 

changes, dentures. Pt’s last dental exam was 6 months ago. 

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

Breast – Denies lumps, nipple discharge or pain. Pt has never had a mammogram. 

Pulmonary System – Denies dyspnea, SOB, cough, wheezing, hemoptysis, cyanosis, orthopnea or PND. 

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

Gastrointestinal System – Admits to tight feeling in abdomen. Denies change in appetite, intolerance to foods, N/V, dysphagia, pyrosis, flatulence, eructation, abdominal pain, diarrhea, jaundice, change in bowel habits, hemorrhoids, constipation, rectal bleeding, blood in stool, stool guaiac/colonoscopy/sigmoidoscopy or pain in flank.

Genitourinary – Admits to urinary urgency. Denies urinary frequency, change in color of urine, incontinence, dysuria, nocturia, oliguria or polyuria.

Males – last prostate exam/PSA 2019. Denies hesitancy, dribbling.

Sexual History – Denies impotence/anorgasmia, sexually transmitted infections or the use of contraception/protection. 

Menstrual and Obstetrical – Denies dysmenorrhea, menorrhagia, metrorrhagia, PMS, postcoital bleeding, vaginal discharge, dyspareunia or menopause. 

Obstetrical History – GTPAL

Musculoskeletal System – Admits to right lower back pain. Denies deformity or swelling, redness or arthritis. 

Peripheral Vascular System – Denies intermittent claudication coldness or trophic changes, varicose veins, peripheral edema or color change. 

Hematologic System – Denies anemia, easy bruising or bleeding, lymph node enlargement or history of DVT/PE. 

Endocrine System – Denies polydipsia, polyphagia, polyuria heat or cold intolerance, goiter or hirsutism. 

Nervous System – Denies seizures, loss of consciousness, sensory disturbances (numbness, paresthesia, dysesthesias, hyperesthesia), ataxia, loss of strength, change in cognition/mental status/memory or weakness (asymmetric). 

Psychiatric – Denies depression/sadness (feelings of helplessness, feelings of hopelessness, lack of interest in usual activities, suicidal ideation), anxiety, obsessive/compulsive disorder, or ever seeing a mental health professional. 

Physical Examination:

General: 

Noted good lighting and draping on patient. Average sized male, neatly groomed, good hygiene, looks his stated age. Patient is alert and oriented to person, place and time.

Vital Signs: 

BP: 133/89

R: 16 breaths/min unlabored 

P: 82 beats/min, regular rhythm 

T: 96.9 degrees F (oral) 

O2 Sat: 98% Room Air

BMI: 31.92

Skin, Hair, Nails and Head:

Skin: Warm & moist, good turgor, smooth texture, non-icteric. No thickness, opacities noted. No lesions, masses, scars or tattoos noted. 

Hair: Average distribution and quantity. 

Nails: No clubbing, capillary refill <2 seconds throughout.

Head: Normocephalic, atraumatic, no deformities and specific faces noted, non-tender to palpation throughout.

Eyes:

Symmetrical OU. Eyebrows and eyelashes even distribution, eyelids have no discharge or swelling, lacrimal glands have no excessive tearing, dryness, enlargement or erythema, lacrimal sac not inflamed or swollen. No strabismus, exophthalmos or ptosis. Sclera white, conjunctiva clear. 

No other eye examinations done as per the patient’s request (legally blind). 

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

Visual fields full OU. PERRLA, EOMs intact with no nystagmus. 

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

Ears:

Symmetrical and normal size. No lesions, masses or trauma on external ears. No discharge/foreign bodies in external auditory canals AU. Tympanic membrane pearly white/intact with cone of light in normal position AU. Auditory acuity intact to whispered voice AU. Weber midline/Rinne reveals AC>BC AU.

Nose: 

Symmetrical, no masses lesions or deformities, trauma or discharge. Nares patent bilaterally, nasal mucosa pink & well hydrated. No discharge noted on anterior rhinoscopy. Septum midline without lesions, deformities, injection or perforation. No foreign bodies. 

Sinuses:

Non-tender to palpation and percussion over bilateral frontal and maxillary sinuses. 

Mouth:

Lips – Pink, moist; no cyanosis or lesions. Non-tender to palpation.

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. Non-tender to palpation; continuity intact. 

Teeth – Good dentition / no obvious dental caries noted.

Gingivae – Pink; moist. No hyperplasia; masses; lesions; erythema or discharge. Non-tender to palpation.

Tongue – Pink; well papillated; no masses, lesions or deviation noted. Non-tender to palpation.

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 palpable adenopathy noted.

Thyroid: 

Non-tender; no palpable masses; no thyromegaly; no bruits noted.

Thorax & Lungs: 

Chest – symmetrical, no deformities, no evidence of trauma. Respirations unlabored, no paradoxical respirations or use of accessory muscles notes. Lat to AP diameter 2:1. Non-tender to palpation. 

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

Abdomen: 

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 appreciated. 

Heart:

JVP is 25cm above sternal angle with the head of the bed at 30 degrees. PMI in 5th ICS in mid-clavicular line. Carotid pulses are 2+ bilaterally without bruits. Normal rate and rhythm. S1 and S2 are distinct with no murmurs, S3 or S4. No splitting of S2 or friction rubs appreciated. 

Genitalia: 

External genitalia without erythema or lesions. Vaginal mucosa pink without inflammation, erythema or discharge. Cervix nulliparous, 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.  

Neuro:

Alert and oriented x3. CN’s II-XII grossly intact, DTR’s 2+ bilaterally and symmetric. PSYCH appropriate mood and affect.

Musculoskeletal:

No soft tissue swelling / erythema / ecchymosis / atrophy / or deformities in bilateral upper and lower

extremities. Non-tender to palpation / no crepitus noted throughout. FROM (Full Range of Motion) of all

upper and lower extremities bilaterally.  No evidence of spinal deformities. 

Labs:

Urinalysis:

  • Leukocytes – negative
  • Nitrites – negative
  • Urobilinogen – 4
  • Protein – 30
  • pH – 5
  • Blood – 250
  • Specific gravity – 1.025
  • Ketones – negative
  • Bilirubin – 2
  • Glucose – 150

Assessment & Plan/Management

  • Calculus of kidney
    • Start Tamsulosin HCl Capsule, 0.4 mg, 1 capsule orally once a day for 7 days
    • Referral to: Urology. Reason: recurrent urolithiasis
  • Right lower back pain
    • Toradol (Ketorolac) 60 mg:30 mg, IM on left arm
  • Hypertension
    • Continue BP medication
  • DM2
    • Hold Metformin for possible CT or until seen by urologist