Esther Udo
03/30/2021
New York Presbyterian Hospital, Flushing NY.
Hospital Visit (Internal medicine)
Identifying Data:
Name: Mrs. L
DOB: –/–/–
Date: March 2021
Informant: Self
Chief Complaint: “Pain in my abdomen that started 1 year ago”
History of Presenting Illness:
L.R is a 74-year-old female with PMHx of hypothyroidism, arthritis and right hip joint replacement, presents with diffuse abdominal pain starting from underneath her breast down to her lower abdomen. Pt described the pain as initially intermittent but progressed to constant pain. Pt describes pain as having 10/10 severity and pain is worsened when pressure is applied anywhere on the abdomen. The complains of a lack of enthusiasm due to the pain. She states that she visited her doctor at Weill Cornell hospital in Manhattan a year ago with this complaint of abdominal pain and has been in the hospital ever since. The patient was also diagnosed with hypokalemia during the same hospital visit. The patient believes that the abdominal pain may have been due to her hypothyroidism as she was uncompliant with her medication. Pt states that she is currently well controlled and is awaiting rehabilitation and physical therapy to help with her walking. Pt denies any fever, chills, nausea, vomiting, diarrhea, or dyspnea.
Past Medical History:
Hypothyroidism x 43 years, maintained on Synthroid
Left and Right Hip arthritis and right knee arthritis
Lump in left breast, no lumpectomy. Patient also had itching in right breast as well as result of testing
Fibroids x 40 years ago, patient is maintained on medication
Past Surgical hx:
Right hip replacement x 12 years
Medications:
Synthroid for thyroid disease
Pt does not recall name of other medications
Allergies:
Complains of allergy to metallic suture material
Family history:
Mother – History of familial breast cancer
Father- Heart attack
Brother – is healthy
Social history:
Mrs. L is a married female, married to a man and has a daughter
She states that she smoked a cigarette once in 8th grade but denies any other incidence.
At home, she drinks 1 glass of wine with her dinner
She enjoys eating fish and eats vegetables
She is not religious
Review of Systems:
General: Patient is alert and oriented, denies fever and chills
Breast: She states she has a lump in the left breast
Pulmonary: denies dyspnea
Gastrointestinal system: states she has diffused abdominal pain and denies vomiting
Musculoskeletal system: States she has left and right hip arthritis and right knee arthritis
Endocrine system: she sates that she has hypothyroidism
Vitals:
HR 72, RR 14/min, Temp 97.8, O2 sat 95% on room air, BP: 115/82, BMI: 24.3 (Height-5’8, weight 160lbs)
General Appearance: Pt is alert and Oriented x3, well nourished, comfortable, appears as stated age, in no acute distress.
Skin: African American with even skin tone, has a fully healed 2cm scar on anterior aspect of forearm. No other ecchymosis, laceration, masses, lesions, no moles, no diaphoresis. Skin is warm and dry. Normal hair distribution on the body.
Head: Hair texture is normal and thick, normal distribution of hair on scalp. No seborrhea, no lice or mites, no bruising, bumps or lacerations on scalp. No tenderness on palpation of face. No moon facies, no sign of acromegaly.
Eyes: Pupils are equal, round, reactive to light and accommodation. No periorbital swelling, no strabismus or nystagmus. No lacrimation at this time. No sign of retinal hemorrhage, or bleeding. 20/20 vision on Snellen with prescription glasses.
Ears: No ear discharge, no signs of atresia, no lacerations to pinna, no piercings, no periauricular sinus, no dermatitis. No tenderness to palpation of the auricle. No mastoiditis. No swelling or erythema of the external ear canal. Tympanic membrane is intact bilaterally, appears greyish with no sign of perforation. Cone of light at 7’o clock for left tympanic membrane and 6’ o clock on right tympanic membrane. Equal bilateral hearing with weber test, and air conduction is greater than bone conduction bilaterally with Rinne.
Nose: Patent bilaterally, no septal deviation, no nasal turbinate, no nasal polyps, nose appears moist a with no discharge. No signs of cleft palate. No pain on palpation around the maxillary and frontal sinus.
Neck: No lymphadenopathy noted. Thyroid feels normal.
Mouth (oral): Small 1cm lacerations on the upper lip. No swelling of the upper or lower lips, no ulcers, no blisters, no prominent sebaceous glands. No leukoplakia, no oral candidiasis, patient had tonsillectomy when young. Uvula is midline, no foul odor. Pt is able to move tongue around freely on command.
Pulmonary: not done (still practicing)
Cardiovascular: not done (still practicing)
