Identifying Data

Patient: Sarah Smith

DOB: 11/10/1971

Date and Time: February 2, 2021

Residence: Manhattan

Primary Care Doctor: Dr. Klein

OB/GYN: Dr. Peters

Location: Urgent Care, Queens

Referral: Suggested by friend

Reliability: Reliable

Religion: Catholic

Chief Complaint: “My right leg feels like its been cramping” for the past three days

History of Present Illness

48 year old, recently COVID positive woman with a pmhx of premature ovarian insufficiency and a PMH of Grave’s disease, presents to Urgent Care complaining of intermittent cramping pain in her right leg, onset 3 nights ago. States that the cramping started Saturday night (1/30/21) while she was sitting at her desk. Her cramping episodes occur 4-5 times a day and last 2-3 minutes at a time. She states her pain starts from behind the knee and radiates to her ankle, and after some time, starts to feel like a burning sensation more towards her ankle. She has taken Motrin 400 mg for her cramping, with some improvement. Her leg cramps are exacerbated when she sits for long periods of time, and is alleviated when she walks around. She feels her pain is a 3/10, and states this pain has not affected her daily life. Patient denies any trauma or injury. Denies family history of clotting disorders. States she went dancing a week ago. She denies SOB, fever, chills, chest pain or abdominal pain. Notes increased fatigue, since recovering from COVID. Patient states she has not experienced this in the past.

Past Medical History

Premature ovarian insufficiency x 6 years, well controlled on medication

Grave’s disease, diagnosed 5 years ago, has been in remission for 4 years

COVID- tested positive two weeks ago, and tested negative 3 days ago

Immunizations- Up to date, flu vaccine yearly

Screening test- Pap smear- 9 months ago, normal. Bone scan- 9 months ago, normal. Thyroid ultrasound- 6 months ago, normal. Patient has not undergone mammogram

Past Surgical History

No pertinent surgical history

Medications

Vitamin C 1000 mg, 1 tab PO qd, for COVID precaution, last dose this morning

Vitamin D 2000 mg, 1 tab PO qd for COVID precaution, last dose this morning

Echinacea 400 mg, 1 tab PO qd for COVID precaution, last dose this morning

Estradiol patch 0.05mg transdermal and changes it twice a week-, fort premature ovarian insufficiency

Allergies

Denies food, medication, or environmental allergies

Family History

Mother- 66, diabetes

Father- 70, diverticulitis

Brother- 28, alive and well

Brother- 28, alive and well

Sister- 53, alive and well

Two children, ages 8 and 12, alive and well

Social History

Patient is a married female, living with her husband and two children. She currently works as a computer programmer and frequently drives to different companies and facilities for work.

Habits- She drinks 2-3 glasses of wine a week (approximately 4 oz each glass). She also drinks up to 4 cups of coffee a day, as well as 8 glasses of water a day. Denies current or previous smoking. Denies substance abuse. Denies illicit substance use.

Travel- She has not recently travelled

Diet- States that her diet is inconsistent

Exercise- She currently does Pilates, yoga, and stretches 2x a week

Sexual Hx- Heterosexual, monogamous

Denies use of recreational drugs

Review of Systems (use bates)

General:

• No recent weight loss or weight gain
• No loss of appetite
• Admits to generalized fatigue
• Denies fever, chills, night sweats

Skin, hair and nails

• Denies dryness or sweatiness
• Denies discoloration
• Denies rash
• Denies open wounds
• Admits to bruising in left thigh
• Denies change in hair distribution
• Denies itchiness
• Denies change in pigmentation
• Denies changes in skin texture

Head

• Admits to dizziness; started three days ago; worse in the morning than at night
• Sleep helps the light headedness; nothing makes it worse; has experienced it when she had sinus infection or cold. Light headedness lasts for an hour-2 at a time. She drinks water to stay hydrated, but doesn’t know if that is making it better. Makes it harder for her to get up. No sinus pain or congestion. Never had adequate sleep due to children. Doesn’t feel light headedness at same time as cramps.
• No recent head trauma

Eyes

• No visual changes
• Denies scotoma
• Denies fatigue with use of eyes
• Wears glasses and contacts
• Last eye exam was a year ago- everything was fine
• Denies eye itchiness or discharge
• Denies eye redness

Ears

• Denies tinnitus
• Denies ear pain
• Denies discharge
• Doesn’t wear hearing aids
• Denies deafness

Noses/ Sinuses

• Denies epistaxis
• Denies congestion or discharge
• Denies recent trauma
• Denies dryness
• Denies itchiness
• Denies difficulty breathing through nose

Mouth and throat

• Denies sore throat
• Denies difficulty swallowing
• Denies bleeding gums
• Denies dryness
• Denies ulcers
• Last dental exam 10 months ago; 1 wisdom tooth is still there, but no issues
• Denies sore throat
• Denies dentures
• Denies voice changes
• Denies swelling of tongue
• Denies CPAP or BIPAP use

Neck

• Admits to neck pain, 5 days ago consists 2/10. Doesn’t radiate but it hurts when she moves. She thinks motrin had helped when she takes it for her leg. She can still move her neck. Her pain has become constant for 5 days, has not happened to her before. Pain is sharper with movement. Denies prior trauma or injury to the neck

Breast

• Denies pain
• Denies lumps
• Denies nipple discharge
• Denies mammogram
• Denies swelling

Pulmonary System

• Denies cough or sputum production
• Admits to acid reflux, for the past week. It happens occasionally. She takes TUMS which helps. Food exacerbates it
• Denies chest pain
• Denies hemoptysis
• Denies SOB or dyspnea on exertion
• Denies wheezing
• Denies orthopnea or paroxysmal nocturnal dyspnea

Cardiovascular System

• Denies palpitations
• Admits to irregular heartbeat- skips a beat, noticed this for a few years, but has become progressive for the past couple of days. Has seen a cardiologist in the past but was told it was normal. Dr. Fishweiker.
• Denies heart murmur
• Denies HTN
• Admits to some swelling in both her ankles, more on right; worse at the end of the day; has seen this in the past. In both her pregnancies, her ankles were swollen, but this is less than that.
• Denies syncope
• Denies chest pain

GI

• Admits to heart burn; usually after eating something spicy or oily- starts lower in stomach but travels upward
• Denies loss of appetite
• Denies nausea, vomiting
• Denies diarrhea
• Denies dysphagia
• Denies constipation
• Denies changes in bowel habit
• Bowel movement- 1x a day
• Denies colonoscopy
• Denies rectal bleeding
• Denies jaundice

Genitourinary System

• Denies urgency
• Admits to frequency= 6-7 x
• Denies pain urinating
• Clear urine, brighter in the morning
• Denies hematuria
• Denies incontinence
• Denies STIs
• Admits to menstruation; last menstruation was two months ago and lasted 5 days (medium). She gets her period approx. 8 times a year, not regular. First period was in age 12. Admits to some cramping during periods
• 2 NSVD full-term
• Denies pregnancy
• Admits to sexually active
• Denies contraception
• Denies abnormal discharge or bleeding
• Denies clot size
• Admits to miscarriage approximately 6 years ago, when she was diagnosed with premature ovarian
• Total pregnancies= 3 times- gravida; para= 2
• Admits to spotting, in between periods
• Denies itching/ pain around genitalia
• Denies odor
• Used birth control for 2 years when she was 21
• Denies trauma

Nervous System

• Denies tingling or numbness
• Denies seizure
• Denies weakness
• Denies tremors
• Denies ataxia
• Denies headaches
• Denies numbness, parethesias

Musculoskeletal System

• Denies backpain
• Admits to calf pain, worse when she wits with her feet flat
• Denies joint pain

Peripheral Vascular System

• Admits to cramping in right leg
• Admits to edema
• Denies varicose veins
• Denies color changes

Hematology

• Denies hx of clots
• Denies blood transfusion
• Admits to bruise in left thigh for the past week; admits to bruising in the past but says this lasted very long
•  

Endocrine

• Admits to polyuria- past few years
• Denies polyphagia
• Denies polydipsia
• Admits to heat intolerance
• Admits to excessive sweating
• Denies hirtuism
• Denies hair loss
• Admits to goiter

Psychiatric

• Denies anxiety; gets anxious when she flies
• Takes Xanax 1-2 pills before a flight
• Denies psych meds
• Denies feelings of hoplelessness or helplessness
• She saw mental health professional for 1 year after diagnosed with ovarian; has not returned since
• Denies hallucinations
• Denies OCD