History
Identifying Data
Full Name: J. Medina
Address: Queens, NY
DOB: 12/14/1972
Date and Time: 11/16/2021
Location: NYPQH
Religion: Christian
Source of Information: Self
Reliability: Reliable
Source of Referral: Self
Chief complaint: “I was feeling weak for a few days and then I fell”
History of Present Illness: 46 year old male with no significant PMH comes to the ER complaining of generalized weakness for the past 3 days. He came to the ER at 4:30 am yesterday after experiencing a fall in the bathroom. He had no signs of trauma after his fall. Upon examination in the ER, he was told his blood pressure was very low. He had a similar experience 3 days prior while on the train. Upon further assessment, he was then told that he also had a GI bleed and is scheduled for an endoscopy later today. Admits to dark colored stool. He admits to experiencing dyspnea, diaphoresis, and palpitations along with weakness, but denies fever, chills, abdominal pain and vomiting. States he is feeling better since being admitted to the hospital.
Past Medical History
Past history of hepatitis 15 years ago (does not know what type of Hepatitis)
Denies childhood illnesses
Immunizations- Up to date; has not received flu shot
Past Surgical History
Denies past surgical history
Medications
Denies taking medications
Allergies
Denies allergies
Family History
Mother- alive, healthy, no reported health issues
Father- alive, healthy, no reported health issues
2 sisters, 1 brother- alive, healthy, no reported health issues
Social History
M. Jose is a married male, living with his wife and child. He currently works as a chef.
Habits- He drinks up to 3-4 beers on the weekends. Denies present and past tobacco use. Denies history of substance abuse, denies history of illicit substance use. Drinks 1 cup of coffee a day.
Travel- He has not travelled recently
Diet- He eats well balanced meals with protein, fruits, and vegetables
Exercise- He does not exercise regularly
Sexual Hx- He is heterosexual, monogamous, sexually active, and does not use protection
Review of Systems
General- Admits to generalized weakness and fatigue. Denies recent weight loss or gain, loss of appetite, fever or chills, or night sweats
Skin, hair, nails- Denies changes in texture, excessive dryness or sweating, discolorations, pigmentations, moles, rashes, pruritus, or changes in hair distribution
Head- admits to current, mild headaches, but denies vertigo, or head trauma
Eyes- Denies visual disturbances. Does not wear glasses.
Ears: Denies tinnitus or hearing changes
Nose/Sinuses- Denies obstruction, post nasal drip or epistaxis
Mouth/throat- Denies bleeding gums, sore throat, sore tongue, mouth ulcers, voice changes or use of dentures.
Neck: Denies swelling, tenderness, pain or difficulty swallowing
Pulmonary system- Admits to dyspnea. Denies cough, sputum production, wheezing, hemoptysis, or orthopnea.
Cardiovascular system- Admits to palpitations and diaphoresis. Denies chest pain, hypertension, edema in the ankles/ feet, syncope or known heart murmur.
Gastrointestinal system- Has regular bowel movements daily. Denies change in appetite, intolerance to specific foods, nausea, vomiting, dysphagia, pyrosis, unusual flatulence or eructation, abdominal pain, diarrhea, jaundice, constipation, rectal bleeding or blood in stool.
Genitourinary system- Denies urinary frequency or urgency, nocturia, oliguria, polyuria, dysuria, incontinence, awakening at night to urinate or flank pain
Nervous- Admits to weakness. Denies seizures, , loss of consciousness, loss of strength, or change in cognition/ mental status/ memory,
Musculoskeletal system- Denies muscle/ joint pain, deformity or swelling, redness or arthritis
Peripheral vascular system- Denies intermittent claudication, coldness or trophic changes, varicose veins, peripheral edema or color changes
Hematological system- Denies anemia, easy bruising or bleeding, lymph node enlargement, blood transfusion, or history of DVT/PE
Endocrine system- denies polyuria, polydipsia, polyphagia, heat or cold intolerance, excessive sweating, hirsutism, or goiter
Psychiatric- Denies depression/ sadness, anxiety.
Physical
General:
Slender male, neatly groomed, looks like his stated age of 46
Vital Signs:
Height- 66 in.
Weight- 155 lbs
T: 98.6 F
P: 60, regular
O2 sat: 98% room air
R: 20/ min, unlabored
BP: 110/60
Skin: Warm and moist, good turgor. Nonicteric, no lesions, no scars, no tattoos
Hair: Thick and full, even distribution throughout head. No signs of nits.
Nails: No clubbing, capillary refill < 2 seconds in upper and lower extremities
Head: Normocephalic, atraumatic, non-tender to palpation throughout
Ears: Symmetrical and appropriate in size. No masses, lesions, or trauma on external ears. No signs of discharge or foreign bodies in external auditory canals AU. TMs pearly white/ intact with light reflex in good position AU. Auditory acuity intact to whispered voice AU. Weber midline/ Rinne reveals AC> BC AU.
Nose: Symmetrical, no masses, lesions, deformities, trauma, discharge. Nares patient bilaterally. Nasal mucosa well hydrated. No deviated septum. No discharge noted on anterior rhinoscopy. No foreign bodies.
Sinuses: non tender to palpation and percussion over bilateral frontal and maxillary sinuses
Eyes: Symmetrical OU. No strabismus, exophthalmos or ptosis. Sclera white, cornea clear, conjunctiva pink
Visual acuity uncorrected- 20/20 OS, 20/20 OD, 20/20 OU
Visual fields full OU. PERRLA. EOMs intact with no nystagmus
Fundoscopy- Red reflex intact OU. Cup to disk ration < 0.5 OU. No AV nicking, hemorrhages, exudates or neovascularization OU.
Lips: pink, moist, no cyanosis or lesions. Non-tender to palpation
Mucosa: pink; well hydrated. No masses; lesions noted. Non-tender to palpation
Teeth: good dentition/ no obvious dental caries noted
Gingivae: Pink; well papillated; no masses, lesions or deviation. Non-tender to palatpion
Oropharynx: well hydrated; no injection, exudates, masses, lesions, foreign bodies. Tonsils present with no injection or exudate. Uvula pink, no edema, lesions
Neck: Trachea midline. Supple; non-tender to palpation. No stridor noted, no thrills, bruits. No cervical adenopathy noted.
Thyroid: non-tender, no palpable masses; no thyromegaly
Chest: Symmetrical, no deformities, no trauma. Bilateral mastectomy noted. Respirations unlabored/ no paradoxical respirations or use of accessory muscles noted. LAT to AP diameter 2:1. Non-tender to palpation throughout.
Lungs: Clear to auscultation and percussion bilaterally. Chest expansion and diaphragmatic excursion symmetrical. Tactile fremitus symmetric throughout. No adventitious sounds.
Heart: JVP is 2.5 cm above sternal angle with head of the bed at 30 degrees. PMI in 5th intercostal in mid-clavicular line. Carotid pulses are 2+ bilaterally without bruits. Regular rate and rhythm. S1 and S2 are distinct with no murmurs, S3 or S4. No splitting of S2 or friction rubs
Abdomen: Abdomen flat and symmetric with no scars, striae or pulsations. Bowel sounds normoactive in all four quadrants with no aortic/renal/iliac or femoral bruits. Non-tender to palpation and tympanic throughout, no guarding or rebound noted. Tympanic throughout, no hepatosplenomegaly to palpation, no CVA tenderness appreciated
Male Genitalia and Hernias:
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.
Anus, Rectum, and Prostate
No perirectal lesions or fissures. External sphincter tone intact. Rectal vault without masses. Prostate smooth and non-tender with palpable median sulcus Stool brown and Hemoccult negative (Note: report hemoccult ONLY if it was performed).
Cranial Nerve Exam
CN I- correctly identifies coffee and mint odors bilaterally
CNII- visual fields full by confrontation, visual acuity 20/200 OD, 20/100 OS, uncorrected, red reflex present, cream colored discs with sharp borders no hemorrhages, exudates or crossing phenomena
CNIII, IV and Vi- extraocular movements intact, pupils 3 mm OU and reactive to direct and consensual light and accommodation, no ptosis
CN V- face sensation intact bilaterally, corneal reflex intact, jaw muscles strong without atrophy
CVII- correctly identified sweet, salt and sour tastes, facial expressions intact, clearly enunciates words
CNVIII- repeats whispered words at 2 feet bilaterally, Weber- no lateralization, Rinne- AC> BC
CN IX and X- no hoarseness, uvula midline with elevation of soft palate, gag reflex intact, no difficulty swallowing
CNXI- full range of motion at neck with 5/5 strength and strong shoulder shrug
CNXII- tongue midline without fasciculations, good tongue strength
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. Rhomberg negative, no pronator drift noted. Gait steady with no ataxia. Tandem walking and hopping show balance intact. Coordination by rapid alternating movement and point to point intact bilaterally, no asterixis
Sensory
Intact to light touch, sharp/dull, and vibratory sense throughout. Proprioception, point localization, extinction, stereognosis, and graphesthesia intact bilaterally
Reflexes
2+ throughout, negative Babinski, no clonus appreciated
Meningeal Signs
No nuchal rigidity noted. Brudzinski’s and Kernig’s signs negative
Peripheral Vascular: Skin normal in color and warm to touch upper and lower extremities bilaterally. No calf tenderness bilaterally, equal in circumference. Homan’s sign not present bilaterally. No palpable cords or varicose veins bilaterally. No palpable inguinal or epitrochlear adenopathy. No cyanosis, clubbing / edema noted bilaterally.
Upper Extremity: 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.
Lower Extremity: No soft tissue swelling / erythema / ecchymosis / atrophy / or deformities in bilateral upper and lower extremities. Full active range of motion with no crepitus in all upper and lower extremities bilaterally. Full spinal range of motion with no deformities.
Assessment:
46-year-old male with significant past medical history presenting to Internal Medicine to be evaluated for his GI bleed, which was found after he experienced a fall due to generalized weakness
Differential Diagnosis:
Peptic Ulcer Disease- common cause of GI bleed
Benign or Cancerous tumor of colon- cannot rule out cancer
Cirrhosis- can cause upper GI bleed; additionally, hypotension is a well-known complication in patients with cirrhosis
DIC- considering reasons for GI bleed outside of the GI system
Colon Polyps- less likely to cause GI bleed, but is possible
Plan:
GI bleed- strong drinking and eating 4-8 hours prior to endoscopy to ensure stomach is empty. Endoscopy can help rule in/out PUD.
Blood in Stool- do fecal occult blood test, test for H.pylori to rule in/out PUD
Benign or Cancerous tumor of colon and Colon Polyps- colonoscopy, and if anything is found, must do a biopsy
Cirrhosis- send patient for CT of liver
DIC- order PT, Platelet count, D-dimer and Fibrinogen levels
