History
Full Name: Mr. P
Address: Queens, NY
Date of Birth: 3/27/1941
Date & Time: March 9, 2021 8:11 am
Location: NYPQ, Flushing, NY
Religion: n/a
Source of Information: Self
Reliability: Reliable
Source of Referral: Primary Care Physician
Chief Complaint: “There’s a sharp pain in my knee when walking” x 2 years
History of Present Illness:
80-year-old male, non-smoker, COVID negative with PMH of osteoarthritis, hypertension, hyperlipidemia, BPH, and constipation presenting for pre-operative evaluation for left knee replacement surgery c/o sharp pain of 7/10 in his left knee over the previous 2 years. He states the pain has progressively worsened over the 2 years and is exacerbated by walking or standing for extended periods of time and relieved by rest. He describes the pain while walking as sharp and pain while standing as a sensation of “something blocking up” his left knee while experiencing mild discomfort in his right knee as well. Denies taking any new medications, recent trauma, strenuous activity, neck or back pain, nausea, vomiting, headache, dizziness, lightheadedness, fainting, SOB, LOC, chest pain, fever, night sweats, fatigue, weakness, change in appetite, swelling, or edema. Denies history of CAD, diabetes, stroke, malignancy or any previous surgeries, professing mild anxiety about the procedure as a result.
Past Medical History
Hypertension x 20 years, well controlled on Losartan and Labetalol
HLD x 20 years, well controlled on Simvastatin
BPH – last prostate exam 9/20, as per patient, no remarkable findings
Osteoarthritis of knees bilaterally
Past Surgical History
Denies any history of surgery
Medications
Tamsulosin HCl 0.4 mg 1 capsule PO daily
Simvastatin 5 mg 1 tablet PO daily
Losartan Potassium 50 mg 1 tablet PO daily
Labetalol HCl 100mg 2 tablets PO daily
Citracal Maximum Plus (Calcium + Vit D3) 1 caplet daily
Vit. D3 Tab 50 mcg 1 tablet daily
Docusate Sodium (Colace) 100 mg 1 capsule daily
Dulcolax Suppositories as needed
Allergies:
Amoxicillin – hives (last reaction 05-1997)
Family History
Mother – Deceased age 82
Father – Deceased age 77
Social History:
MM is a 80 y/o male married with children
Habits – non-drinker, non-smoker, caffeinated black tea in morning
Travel – denies recent travel
Diet – maintains a well-balanced, strictly vegetarian diet
Exercise – enjoys daily outings for shopping and/or social events
Sleep patterns – nocturia 1-2x/night, sleep otherwise undisturbed
Sexual history – inactive, heterosexual, monogamous
Review of Systems:
General – Denies loss of appetite, recent weight loss or gain, weakness/fatigue, fever or chills, or night sweats
Skin, Hair, Nails – States dry scaly circular lesion on medial calf x 2 weeks, denies discolorations, moles/rashes, changes in hair distribution, excess dryness or sweating, pruritus or changes in texture.
Head – Denies headaches, dizziness, vertigo, or head trauma
Eyes – He utilizes non-prescription reading glasses as needed. Does not remember date of last eye exam. Denies lacrimation, pruritus, visual disturbances, or photophobia.
Ears – Denies deafness, pain, discharge, tinnitus or use of hearing aids
Nose/Sinuses – Denies discharge, obstruction, or epistaxis
Mouth/Throat – Denies sore throat, sore tongue, bleeding gums, ulcers, or use of dentures. Does not recall last dental exam.
Neck – Denies localized swelling/lumps, stiffness, or decreased range of motion
Breast – Denies lumps, nipple discharge, or pain
Pulmonary System – Denies dyspnea, SOB, cough, wheezing, hemoptysis
Cardiovascular System – Has history of hypertension x 15 years. Denies chest pain, irregular heartbeat, edema/swelling of ankles or feet, syncope
Gastrointestinal System – He takes 100 mg capsule Colace daily with Dulcolax suppository as needed with regular bowel movements daily as a result. Denies change in appetite, nausea/vomiting, abdominal pain, diarrhea, intolerance to specific foods, dysphagia, pyrosis, unusual flatulence or eructations, jaundice, hemorrhoids, rectal bleeding or blood in stool.
Genitourinary System – Patient has BPH, nocturia 1-2x/ night with polyuria and last prostate exam 6 months prior. Denies urinary urgency, oliguria, dysuria, incontinence, or flank pain.
Nervous – He professes to memory impairment appropriate with age. Denies seizures, headache, LOC, ataxia, weakness, change in cognition/ mental status.
Musculoskeletal System – He has osteoarthritis of knees with pain of 7/10 in left knee on walking / extended periods of standing. Denies any other muscle/joint pain, deformity, swelling, redness.
Peripheral Vascular System – Denies varicose veins, peripheral edema, color changes, coldness, intermittent claudication
Hematological system – Denies anemia, bruising or bleeding, history of DVT/PE, blood transfusion, or lymph node enlargement
Endocrine system – He experiences nocturia 1-2x/night, polyuria. Denies polyphagia, excessive sweating, hirsutism, goiter, or heat/cold intolerance
Psychiatric – Denies depression/sadness, anxiety, OCD or ever having seen a mental health professional
Physical:
General: Male of medium build, neatly groomed, appearance appropriate for age.
Ear, Nose, & Sinus:
Ear: Symmetrical and appropriate in size. No trauma/lesions/masses on external ears. No foreign bodies or discharge in the external auditory canals AU. TM’s pearly white / intact with light reflex in good position AU. Auditory acuity intact to whispered voice AU. Weber midline / Rinne reveals AC>BC AU.
Nose: Symmetrical / no masses / lesions / deformities / trauma / discharge. Nares patent bilaterally / Nasal mucosa pink & well hydrated. No discharge noted on anterior rhinoscopy. Septum midline without lesions / deformities / injection / perforation. No foreign bodies.
Sinuses: Non tender to palpation and percussion over bilateral frontal, ethmoid and maxillary sinuses.
Vital Signs: BP: R L
166/88 168/90
RR: 18/min, unlabored P: 60, regular
T: 97.3 F O2 Sat: 97% Room air
Height: 66 inches Weight: 155 lbs.
