Warveen Othman

Physical Diagnosis Lab

Spring 2021

Identifying Data:

Patient: Mr. AF

Age: 78 y/o

Sex: Male

Date & Time of encounter: May 18, 2021         9:22AM

Location: NYP Pre-Admission Testing. Queens, NY

Race: Caucasian

Source of Information: Self

Reliability: Fair – pt was unable to provide specific details due to memory deficit

Source of Referral: Surgeon

Chief Complaint: “I have to get this thing drained on June 1st”

History of Present Illness:

78 y/o male former smoker with PMH of ESRD (HD on Tu/Th/Sat), renal CA s/p right nephrectomy, COPD, CAD s/p PCI x1, CHF, gastric ulcer s/p repair, BPH, presenting to the Pre-Admission Testing office for clearance before abdominal wall hematoma drainage on June 1^st. Patient states the hematoma developed right after an abdominal hernia repair about 1 year ago. The mass is in the supraumbilical region and has been constantly the same size for the past year. He characterizes the mass as “hard” and denies any changes to the mass while coughing, laying down, or any other activities. He denies pain in the area of the hematoma, and only complains of having difficulty putting his pants on over this mass; otherwise, he states that it is not bothersome. Patient reports that after the hematoma is drained, there are plans to have a peritoneal catheter placed for peritoneal dialysis, which will occur daily. He currently has a hemodialysis catheter in his chest which he notes will be removed once the PD cath is placed. The pt also complained of a moderately itchy rash to his scalp, neck, and thorax which has been constant since it started about 1 year ago. He takes 3 tabs of hydroxyzine which improves this symptom, but denies any aggravating factors. He is planning to see a dermatologist after his abdominal procedures. Patient notes he also has SOB at rest and on exertion, which he states is his baseline and has not changed within the last year; he attributes this to his COPD and to lack of exercise. Otherwise, the patient denies fever, chills, abdominal pain, nausea, vomiting, chest pain, leg swelling, palpitations, flank pain, dysuria, hematuria, or blood in stool.

Past Medical History:

ESRD – pt reports kidney function of <10%.

Renal cancer, right.

Gastric ulcer with perforation. Over 1 year ago.

BPH

COPD. 30 pack year history. Quit 5 years ago.

CAD s/p PCI x1 about 5 years ago.

CHF – last echo done in 2020, pt could not recall EF or any other results.

Arthritis

Ambulatory dysfunction – patient ambulates with a walker.

Chronic constipation.

Vision impairment, bilateral. Wears glasses for both reading and far sight. Last saw optometrist within the last year.

Vitamin D deficiency.

Immunizations – Up to date, including COVID. 

Colonoscopy within the last 5 years.

Denies recent hospitalizations.

Past Surgical History:
Right nephrectomy ~40 years ago. – No chemo or radiation therapy.

Perforated gastric ulcer repair.

Supraumbilical hernia repair. 2020

Right hip replacement – pt unable to recall date.

Right knee replacement, total – pt unable to recall date.

Denies past blood transfusions. Denies history of stroke or DVT.

Medications:  *Pt presented with inaccurate medication list and was unable to recall the dosage or timing of some medications he reported.*

Tamsulosin – for BPH. Taken PO, nightly.

Sevelamer – to maintain phosphorus levels with dialysis. Taken PO with each meal, daily.

Furosemide – for CHF. 80mg taken PO, BID.

Calcitriol – for vitamin D deficiency. Taken daily.

Metoprolol – for CHF. 25mg taken PO, BID.

Aspirin – for CAD. 81mg PO daily.

Simvastatin – for CAD. Taken nightly.

Omeprazole – for Hx of gastric ulcer.

Hydroxyzine – for rash. 3 tabs daily.

Trelegy – for COPD but patient is noncompliant with this medication.

Allergies:

Lactose intolerant.

Denies any other drug, environmental, or food allergies.

Family History:

Noncontributory.

Social History:

Mr. AF lives with his wife. He is able to complete ADL without assistance. He is retired.

Habits – Denies caffeine intake, current tobacco use, alcohol use. Denies history of illicit substance use.

Sleep – no complaints

Travel – No recent travel.

Exercise – Patient states he gets most of his exercise when he walks around his dialysis facility 3x a week. Otherwise, he does not exercise much.

Safety measures – patient ambulates with a walker.

Review of Systems:

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

Skin/nails – (+)rash. Denies new moles, erythema, change in pigmentation, changes in hair distribution, or wounds.

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

Eyes – (+) vision impairment (chronic). Denies photophobia, itchiness, redness, tearing, or discharge.

Ears –Denies change in hearing, tinnitus, otalgia, discharge. No hearing aid use.

Nose – Denies congestion, discharge, epistaxis, itchiness.

Mouth/throat – Denies loose teeth, sore throat, difficulty swallowing, bleeding gums, dryness, ulcers, tongue pain, swelling. No dentures. Would like dental evaluation in the near future.

Neck – Denies pain, stiffness, limited ROM, lumps, injury/trauma.

Pulmonary – (+)SOB, DOE – unchanged from baseline. (+)wheezing – occasional, attributed to COPD. Denies cyanosis, orthopnea, PND, hemoptysis. Sleeps with 1 pillow for comfort.

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

GI – (+)constipation – chronic (pt could not recall OTC med). Denies nausea, vomiting, diarrhea, abdominal pain, excessive belching, rectal bleeding. No recent changes in BM.

Genitourinary – (+)“urine comes out slow” – pt attributes to decrease kidney function. Denies dark urine, incontinence, urgency, dysuria, hematuria, frequency.

Nervous –Denies weakness, tingling, numbness, seizures, confusion.

Musculoskeletal –  (+)ambulatory instability – uses walker. Denies body aches, back pain, joint pain, claudication.

Hematologic – (+)easy bruising – pt attributes to aspirin. Denies history of DVT/PE, blood transfusions.

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

Psychiatric – Denies depression, suicidal thoughts, or hallucinations.

Physical Exam:

Vital signs:      BP: Seated                  R-arm: 135/65             L-arm: 131/65

RR:      16 breaths/min, unlabored

Pulse: 69  bpm, regular

T:        97.1 degrees F (oral)  

O2 Sat: 97% on room air

Height: 70 inches        Weight: 187 lbs.       BMI: 26.8.

General: Pt alert, oriented. No acute distress. Well nourished. Looks stated age.

Skin:  (+)scar over right knee (s/p knee replacement), well healed.

(+)vertical, linear scar measuring ~14cm midline in the supraumbilical region, well healed.

(+)1cm, circular pustule in the abdominal RUQ with surrounding erythema.

(+)hemodialysis catheter located in right upper chest with dry, clean dressing and tape; no surrounding warmth, erythema, drainage, or other signs of infection.

(+)ecchymosis to dorsum of hands bilaterally.

Otherwise, skin is warm & moist. poor skin turgor (pt is elderly). Nonicteric, no other lesions noted, no tattoos. No rashes appreciated (although pt c/o “itchy rash”).

Hair:   average quantity and distribution.

Nails:  no clubbing, capillary refill <2 seconds in upper extremities.

Head:   normocephalic, atraumatic, nontender to palpation throughout

Ear: Symmetrical and appropriate in size.  No lesions, masses, trauma on external ears. No mastoid tenderness b/l. (+)Mild amount of cerumen in auditory canals bilaterally. No discharge or other foreign bodies in external auditory canals.  Right and left TM pearly white and fully intact with cone of light in good position. 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.

(+)Poor dentition. No loose teeth.

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. PERRLA.
Visual fields full OU.  EOMs intact with no significant nystagmus.
Fundoscopy – Red reflex intact OU. Could not assess cup to disk ratio. No hemorrhages or exudates visualized.

Visual acuity uncorrected: 20/40 OD, 20/40 OS, 20/40 OU.

Chest/Pulmonary: Chest is symmetrical, without deformities or trauma. Lat to PA diameter is 2:1. Respirations unlabored. No use of accessory muscles noted. Chest nontender to palpation throughout. Lungs CTA and percussion bilaterally. (+)slight wheeze heard in left lower lung, which cleared after cough. Otherwise no rhonchi, rales, or other adventitious sounds. Chest expansion and diaphragmatic excursion symmetric. Tactile fremitus symmetric throughout.

Heart: Regular rate and rhythm. Distinct S1 and S2. No murmurs, S3, S4, friction rubs, or splitting of S2 appreciated. PMI in 5^th ICS in mid-clavicular line.

Carotid pulses are 2+ bilaterally without bruits. JVP is 2cm above the sternal angle with head of the bed at 30°.

Abdomen: (+)large, round, firm, nonmobile, nontender mass in the midline, supraumbilical region, measuring ~12cm. No erythema, warmth, or pulsations noted. Abdomen otherwise nontender to palpation, no guarding or rebound. Tympanic throughout. No hepatosplenomegaly. Abdomen otherwise flat, soft, symmetric. No scars, striae or pulsations noted. Bowel sounds normoactive in all 4 quadrants. No renal, iliac, or femoral bruits. No CVA tenderness noted.