History
Identifying Data:
Full Name: YC
Address: Queens, NY
Date of Birth: 3/27/1998
Date & Time: April 6, 2021 9:25 am
Location: NYPQ, Flushing, NY
Religion: N/A
Source of Information: Self
Reliability: Reliable
Source of Referral: Self
Chief Complaint: “headache and my vision is blurry” x 1 month
History of Present Illness:
23-year-old male, COVID negative with PMH of HTN c/o headache with blurry vision over previous month. The headache is described as feeling like a constant pressure behind the eye with 4/10 pain that was relieved by 1 dose of 325 mg of Tylenol and worsened by staying up late into the night. Pain does not radiate. Patient denies recent weight loss, weakness/fatigue, fever, chills, recent trauma, dizziness, light-headedness, vertigo, lacrimation, photophobia, pruritus, localized swelling/lumps, shortness of breath, dyspnea on exertion, chest pain, palpitations, edema, syncope, loss of consciousness, seizure, change in memory/cognition/mental status, lymph node enlargement. Patient’s vision is uncorrected and does not recall last eye exam. Patient was hesitant to seek professional evaluation until previous Thursday 4/1/21 although symptoms began 3 weeks prior to that. Patient assumed the headache and blurry vision would resolve without intervention.
Past Medical History
Hypertension, on Korean military service exam at 18 y/o, resolved with recent weight loss, as per patient
Past Surgical History
Denies any history of surgery
Medications
Tylenol OTC 325mg tablet PO PRN
Allergies:
NKDA
Family History
Mother – 48, alive and well
Father – 50, alive and well
Paternal Grandfather – deceased x 10 years, stomach cancer
Paternal Grandmother – 74, alive and well
Maternal Grandfather – 76, alive and well
Maternal Grandmother – 75, alive and well
Social History:
YC is a 23 y/o single male
Habits – never drinker, no tobacco use ever
Home – lives at home with mother
Travel – denies recent travel
Diet – maintains a well-balanced healthy diet as of 3 years prior, oatmeal & fruit breakfast
Exercise – soccer games 2-3 times per week
Sleep patterns – sleeps well, approximately 7-8 hours per night
Sexual history – inactive, heterosexual, denies history of sexually transmitted disease
Review of Systems:
General – Denies loss of appetite, recent weight loss or gain, weakness/fatigue, fever or chills, or night sweats
Skin, Hair, Nails – Denies discolorations, moles/rashes, changes in hair distribution, excess dryness or sweating, pruritus or changes in texture.
Head – Has headache x 1 month, denies dizziness, vertigo, or head trauma
Eyes – Complains of blurry vision x 1 month. Vision is uncorrected. 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. Last dental exam 2 years prior.
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 – Past history of hypertension resolved with recent weight loss. Denies chest pain, irregular heartbeat, edema/swelling of ankles or feet, syncope
Gastrointestinal System – 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 – Denies urinary urgency, oliguria, dysuria, incontinence, or flank pain.
Nervous – Denies seizures, changes in memory, LOC, ataxia, weakness, change in cognition/ mental status.
Musculoskeletal System – Denies 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 – Denies polyphagia, nocturia, polyuria, 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.
Eyes:
Eyes: appear symmetrical OU. No ptosis, strabismus, exophthalmos noted. Sclera is white, cornea clear, and conjunctiva pink.
Visual acuity is uncorrected – 20/25 OS, 20/25 OD, 20/25 OU
Visual fields full OU. PERRLA. EOMs intact with no nystagmus
Fundoscopy: Red reflex is intact OU. Cup to disc ratio < 0.5 OU. No hoemorrhages, exudates or neovascularization OU.
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.
Mouth & Throat
Lips: Lips appear moist & pink, no cyanosis, erythema, masses or lesions. Non-tender to palpation
Mucosa: Pink & moist, no masses, lesions, non-tender to palpation, no leukoplakia noted.
Palate: Pink & moist, no masses, lesions, scars. Non-tender to palpation with continuity intact
Teeth: Good dentition with no dental caries noted
Gingivae: Pink, moist. No hyperplasia, masses, lesions, erythema or discharge. Non-tender to palpation
Tongue: Well papillated & pink, no masses lesions or deviation. Non-tender to palpation
Oropharynx: Well hydrated with no exudate, erythema, masses, lesions, foreign bodies. Tonsils are present, grade 1, with no injection or exudate. Uvula is midline, pink, with no lesions or edema.
Neck
Neck: No masses, lesions, scars, pulsations noted with trachea midline. Neck is supple and non-tender to palpation. No stridor noted. 2+ carotid pulses with no thrills; bruits are noted bilaterally, with no cervical adenopathy noted.
Thyroid: No palpable masses, no thyromegaly or bruits. Non-tender to palpation.
Thorax & Lungs:
Chest: Symmetrical, no trauma, no deformities. 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.
Cardiac:
Heart: PMI in 5th ICS in midclavicular line. Carotid pulses are 2+ bilat, no bruits noted. Rate and rhythm regular (RRR). Distinct s1 and s2 with no murmurs, no s3 or s4. No friction rubs or split s2 appreciated.
Abdomen:
Abdomen is flat and symmetric without 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.
Vital Signs: BP: R L
110/62 – contraindicated by IV placement
112/62
RR: 20/min, unlabored P: 60, regular
T: 98.7 F O2 Sat: 99% Room air
Height: 70 inches Weight: 155 lbs.
