Identifying Data:

Patient: Mr. GB

Age: 48 y/o

Sex: Male

Date & Time of encounter: November 30, 2021            9:10AM

Location: NYP – PreAdmission Testing. Queens, NY

Race: African American

Source of Information: Self

Reliability: Reliable

Source of Referral: Self

Chief Complaint: “I have to get this hernia fixed” x several years

History of Present Illness:

48 y/o male with PMHx of HTN and OSA, presenting to PreAdmission Testing for clearance for an umbilical hernia repair scheduled for 12/16/2021. Patient states that he has had this umbilical hernia for several years now (cannot recall when it exactly started), and noticed for the past few months that it has become mildly painful, only when he tries to compress it. He is still able to reduce the hernia, but it protrudes easily with several activities (coughing, laughing, or standing up from sitting position too quickly). He does not wear belts or any other gear to compress the hernia. He recently saw his PCP and surgeon who reportedly both recommended to proceed with the repair. Pt also mentions that he often feels embarrassed when the protruding hernia is noticed through his clothes. Otherwise, he denies any other abdominal pain, constipation, diarrhea, blood with stool, changes in bowel movements, nausea, vomiting, fever, or appetite change.

Past Medical History:

Hypertension

Obstructive sleep apnea – patient uses CPAP occasionally

Vision impairment – pt wears glasses. Last eye exam this year.

Immunizations – Up to date

Colonoscopy: last one this year, patient reports no abnormalities. 

Denies recent hospitalizations.

Past Surgical History:

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

Medications: 

Olmesartan – 40mg PO once daily. *Pt notes he is not always compliant, stating he did not take his dose today.

Multivitamin – one capsule daily.

Allergies:

Denies any drug, environmental, or food allergies.

Family History:

Noncontributory. Denies family history of hypertension.

Social History:

Mr. GB lives with his daughter and wife. His wife will be assisting him post-op. He works in IT for electronic medical records. He has been working remotely from home.  

Habits –Denies smoking history. Drinks occasionally (<1 a week). Denies history of illicit substance use.

Exercise – Patient walks ~5 miles every morning.

Sleep – patient complains of poor sleep quality recently. Notes the CPAP is “annoying” and makes it even more difficult to sleep.

Travel – No recent travel.

Review of Systems:

General – (+)weight loss – intentional, -10lbs in 3 months. Denies recent fever, chills, fatigue, night sweats, or change in appetite.

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

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

Eyes –(+)glasses. Denies visual disturbances, 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 sore throat, difficulty swallowing, bleeding gums, dryness, ulcers, tongue pain, swelling.

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

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

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

GI – (+)hernia protrusion, pain with reduction. Denies other abdominal pain, nausea, vomiting, diarrhea, constipation, excessive belching, rectal bleeding. No recent changes in BM.

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

Nervous – Denies weakness, numbness, tingling, seizures, confusion, or gait change.

Musculoskeletal – Denies body aches, back pain, joint pain, claudication.

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

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

Psychiatric – Denies suicidal thoughts, depression, or hallucinations.

Physical Exam:

Vital signs:      BP: Seated                  L-arm: 146/103           R-arm: 140/95

RR:      16 breaths/min, unlabored                 

Pulse: 85  bpm, regular                     

T:        98.6 degrees F (oral)

O2 Sat: 99% on room air

Height: 73 inches        Weight: 255 lbs.       BMI: 33.6

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

Skin: Skin is warm & moist throughout. No ecchymosis. Nonicteric, no lesions noted, no tattoos. No rashes appreciated. No discoloration.

Hair:  (+)alopecia (appropriate to male pattern baldness)

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.

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.

Mouth/Oropharynx : Lips appear pink and moist, with no masses, cyanosis, or ulcers. Mucosa 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 bilaterally. No cervical adenopathy noted. Thyroid is non-tender with no palpable masses. No thyromegaly.

Eyes : Eyelids without lesions, edema, or discharge. No strabismus, exophthalmos or ptosis.  Sclera white, conjunctiva pink bilaterally. PERRLA. EOMs intact with no significant nystagmus.
Visual fields full OU. Visual acuity corrected: 20/20 OD, 20/20 OS, 20/20 OU.
Fundoscopy – Red reflex intact OU. No hemorrhages or exudates visualized.

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 bilaterally. No wheezes, rhonchi, rales, or other adventitious sounds. Chest expansion and diaphragmatic excursion symmetric. Tactile fremitus symmetric throughout.

Cardiac: 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: (+)2cm, reducible (I wasn’t comfortable with actually reducing it), mildly tender mass to the right side of the umbilicus. Not pusatile. No discoloration. Obese abdomen. Rest of abdomen nontender to palpation, no guarding or rebound. Tympanic throughout. No hepatosplenomegaly. Abdomen flat, soft, symmetric. No scars, striae or pulsations noted. Bowel sounds normoactive in all 4 quadrants, no significant bowel sounds heard over the mass. No renal, iliac, or femoral bruits. No CVA tenderness noted.

Genitourinary: Circumcised male. No penile discharge or lesions. No scrotal swelling or discoloration. Testes Descended bilaterally, smooth and without masses. Epididymis nontender. No inguinal or femoral hernias noted.

Rectal: No perirectal lesions or fissures. External sphincter tone intact. Rectal vault without masses. Prostate smooth and non-tender with palpable median sulcus Stool brown.

Mental Status Exam: Appearance and behavior – patient alert, no abnormal movements, grooming/hygiene appropriate, appropriate facial expression and manner.

Speech and language – follows 2 stage commands. Is able to repeat words and name objects. Speech is of appropriate quantity, rate, volume, flow, and articulation.

No SI/HI, no feelings of rage, sadness, or anxiety.

Conversation progresses logically towards a goal. No delusions, hallucinations, phobias, obsessions.

Insight and judgement intact/appropriate.

Oriented to name, date, time, location. Digit span to 5 numbers. Serial 7s x5. Pt able to spell “world” forward and backwards. Remote and recent memory seemed intact (but could not verify at the time). Recall 3/3.

Able to name president. Follows 3 stage commands. Calculating ability intact. Abstract thinking and constructional ability intact.

Neurologic:

Cranial Nerves – See “Eyes” for CN II assessment. Conjugate gaze without nystagmus. Convergence of eyes. No ptosis. Facial sensation present and equal bilaterally. Symmetric and fluid facial movements. No difficulty with BMP speech sounds. Strong eye muscles that hold eye closed against resistance. See “Ear” for CN VIII.

Soft palate rises and uvula remains midline. No hoarseness or nasal quality in voice. No facial droop.

Strong neck and shoulder muscles against resistance bilaterally. Strong and symmetric tongue. No difficulty with LTND speech sounds.

Peripheral Neuro –

Motor/Cerebellar: Full active/passive ROM of all extremities without rigidity or spasticity. Symmetric muscle bulk with good tone. No atrophy, tics, tremors or fasciculation. Strength 5/5 throughout, including grip strength.  Rhomberg negative, no pronator drift noted. Gait steady with no ataxia. Coordination by rapid alternating movement and point to point intact bilaterally, no asterixis

Reflexes: 2+ throughout, negative Babinski, no clonus appreciated

Meningeal Signs: No nuchal rigidity noted. Brudzinski’s and Kernig’s signs negative.

Musculoskeletal: No soft tissue swelling / erythema / ecchymosis / atrophy / or deformities in bilateral upper and lower extremities. Non-tender to palpation / no crepitus noted throughout. FROM (Full Range of Motion) of all upper and lower extremities bilaterally.  No evidence of spinal deformities.  

Differential Diagnoses: (from most likely to least likely)

• Umbilical hernia, without incarceration/strangulation – most likely given history
• Rectus abdominis diastasis – less likely given size of mass.
• Benign lipoma – less likely as mass is slightly tender and reducible
• Malignant tumor – less likely given history. Still considered as pt has lost 10 lbs in 3 months, although this was intentional (with exercise).
• Hematoma – less likely given mass has been present for several years.
• Abdominal wall abscess – less likely due to lack of erythema, warmth, fever, or other signs of infection.