Warveen Othman

Physical Diagnosis Lab

Spring 2021

Identifying Data:

Patient: Mr. JL

Age: 54 y/o

Date & Time of encounter: March 23, 2021      9:20AM

Location: NYP Emergency Department, Queens, NY

Source of Information: Self

Reliability: Reliable

Source of Referral: self

Mode of transport: drove self

Chief Complaint: “My back is hurting” x 2 days

History of Present Illness:

54 y/o male, last tested COVID negative 2 weeks ago, with PMH of vertigo, chronic b/l knee pain, presenting to the ED today c/o 3 months of intermittent, non-radiating, mid back pain which became worse yesterday. Pain has become constant in the last 2 days and is of burning quality. He notes that he was relaxing at home when it began. Pt states pain was of 9/10 severity but has now decreased to 7/10 since arriving in the ED. He denies any aggravating factors. In the past, pt used Tylenol 500mg for relief of his back pain; yesterday, however, this did not help. He reports going to Mt. Sinai’s ED in Astoria, NY yesterday for this complaint. Pt states imaging was not done at that time and he was given “an injection and some pills,” which only temporarily helped his pain. At discharge, he was prescribed cyclobenzaprine and methocarbamol, which he reports have only minimally improved his pain, thus prompting his ED visit here. Today, he is requesting a CT of his back. He denies any injuries or trauma to his back. Pt mentions his job consists of cleaning buildings which includes heavy lifting and ambulating several flights of stairs. He denies chest pain, SOB, DOE, weakness, numbness, difficulty walking, abdominal pain, fever, headache, or loss of consciousness. Of note, pt states he was in Ecuador for 3 months before returning to the US 2 weeks ago; he was seen by a physician there for the back pain and was only advised to lose weight. Otherwise, Mr. JL has not seen a doctor in years despite being assigned a PCP in NY by his insurance. 

Past Medical History:

Vertigo – diagnosed 4 years ago, pt states condition is better now

Chronic bilateral knee pain

Partial edentulism – pt states due to poor dental hygiene in the past. Now regularly sees a dentist in Ecuador. Last seen 2 months ago.

Vision impairment – pt wears reading glasses. Has not seen an optometrist in several years.

Onychomycosis – left hand: 1^st, 3^rd, 4^th, and 5^th digits.

Immunizations – No COVID vaccinations yet. Otherwise up to date, including flu vaccine this year.

Denies hospitalizations.

Past Surgical History:

Denies history of surgeries.

Denies past blood transfusions. Denies injuries.

Medications:

Tylenol 500mg PRN for back and knee pain. Last dose yesterday.

Cyclobenzaprine 10mg BID, as needed for back pain. Last dose this morning.

Methocarbamol 750mg 4x a day. Last dose this morning.

Allergies:

Denies any drug, environmental, or food allergies. (NKDA)

Family History:

Mother – 76, alive and well. History of hypertension.

Father – deceased at age 74, “natural causes.” Unknown PMH.

Brother – 49, alive and well.

Children (2) – both alive and well.

Denies family history of CAD, DM, or cancer.

Social History:

Mr. JL is a married male, living with his wife and 2 kids. He works full time as a custodian.

Habits – Drinks about 1 beer a week. Drinks 1 cup of a coffee daily. Denies past and present tobacco use. Denies history of substance abuse, denies history of illicit substance use.

Sleep – no complaints

Travel – Patient flew from Ecuador 2 weeks ago.

Exercise – States he gets most of his exercise through work by cleaning and ambulating flights of stairs.

Sexual Hx – Heterosexual, monogamous.

Review of Systems:

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

Skin/nails – (+) onychomycosis of the left 1^st, 3^rd, 4^th, and 5^th fingers. Denies rash, new moles, erythema, itchiness, change in pigmentation, changes in hair distribution, or wounds.

Head –Denies headache, dizziness, lightheadedness, recent head trauma,

Eyes – Denies new blurriness, double vision, loss of vision, fatigue, photophobia, itchiness, redness, tearing, or discharge. Wears reading glasses. Unsure of when last eye exam was.   

Ears – Denies tinnitus, otalgia, discharge, deafness. No hearing aids.

Nose –Denies congestion, discharge, anosmia, epistaxis, itchiness.

Mouth/throat – (+)partial edentulism. Denies sore throat, difficulty swallowing, bleeding gums, dryness, ulcers, tongue pain, swelling. Last dental exam 2 months ago. No dentures.

Neck –Denies pain, stiffness, limited ROM, lumps, injury or trauma to the neck.

Pulmonary – Denies cough, sputum production, SOB, DOE, wheezing, cyanosis, orthopnea, PND, hemoptysis. Sleeps with 1 pillow for comfort.

Cardiovascular – Denies chest pain, lower extremity swelling, syncope, known heart murmur.

GI – (+)diarrhea 2 days ago, nonbloody, now resolved. Denies nausea, gastric reflux, vomiting, abdominal pain, excessive belching, rectal bleeding. No changes in BM. No colonoscopy.

Genitourinary – Denies dark urine, urgency, dysuria, difficulty urinating, hematuria, frequency, incontinence.

Never had a prostate exam.

Nervous – Denies tingling, numbness, seizures, weakness, memory changes, changes in balance.

Musculoskeletal –  (+)back pain. (+)bilateral knee pain (chronic). Denies other body aches, other joint pain, claudication.

Hematologic – Denies history of DVT/PE, blood transfusions. Denies easy bleeding or bruising.

Endocrine – Denies polydipsia, polyphagia. Denies heat or cold intolerance.

Psychiatric – Denies depression, suicidal thoughts, or hallucinations.

Physical Exam:

Vital signs:      BP: Seated                  R-arm: 162/90             L-arm: 168/96

RR:      16 breaths/min, unlabored

Pulse: 66  bpm, regular

T:        98.6 degrees F (oral)

O2 Sat: 97% Room air

Height: 61 inches        Weight: 202 lbs.       BMI: 38.2

General: Pt sleeping but easily arousable. No acute distress. Obese male. Looks stated age.

Skin:  (+)multiple scars scattered around scalp (pt attributes to minor injuries from childhood).warm & moist, good turgor. Nonicteric, no lesions noted, tattoos.

Hair:   average quantity and distribution.

Nails:  (+)1^st, 3^rd, 4^th, and 5^th digits of left hand with white discoloration of nail plates, thickened nails, with partial separation from nail bed.Left 2^nd digit and digits of right hand without abnormalities. no clubbing, capillary refill <2 seconds in upper extremities.

Head:   normocephalic, atraumatic (no new trauma), non tender to palpation throughout

Ear: Symmetrical and appropriate in size.  No lesions, masses, trauma on external ears. No mastoid tenderness b/l. No discharge or foreign bodies in external auditory canals.  Right TM pearly white and fully intact with cone of light in good position. (+)Left TM only partially visualized due to cerumen obstructing view; partially visualized TM was pearly white. Auditory acuity intact to whispered voice.  Weber midline / Rinne reveals AC>BC bilaterally.

Nose – (*Deferred due to COVID-19*). 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 – Nontender to palpation and percussion over the frontal, ethmoid and maxillary sinuses.

Mouth/Oropharynx – (*Deferred due to COVID-19*). Lips appear pink and moist, with no masses, cyanosis, or ulcers.

(+) Several missing teeth. Poor dentition. Mucosa is pink and moist; no lesions or masses. No leukoplakia. Palate pink, moist, intact with no lesions, masses, or scars. No gingival hyperplasia or recession. Tongue is midline. No discharge, masses or lesions. Uvula is midline and rises symmetrically with phonation. No edema or lesions.

Oropharynx is pink and moist. Tonsils are symmetric and without hypertrophy. No swelling, erythema, exudates, masses/lesions, foreign bodies. Tonsils are grade I. Mallampati Class I.

Neck – Full ROM. Supple. Non-tender to palpation. No JVD. Trachea is midline. No masses or lesions. No scars. Lymph nodes non-palpable bilaterally. No stridor. 2+ carotid pulses. No cervical adenopathy noted.

Thyroid is non-tender with no palpable masses. No thyromegaly.

Eyes – Symmetric. Eyelids without lesions, edema, or discharge. No strabismus, exophthalmos or ptosis.  Sclera white, conjunctiva pink bilaterally. (+)small dark brown nevus noted on left eye (pt notes he has had this since childhood).
(Pt refused visual acuity) Visual acuity uncorrected – 20/20 OS, 20/20 OD, 20/20 OU
Visual fields full OU.  PERRLA ,  EOMs intact with no significant nystagmus.
Fundoscopy – Red reflex intact OU. Could not assess cup to disk ratio. No hemorrhages or exudates visualized.