History and Physical # 2

Patient: Mr. M., 65 year old Gender: Male   Date: 11/3/2017     Examiner: Carolina Munoz

Problem List:

• Hypertension (1996), Active
• Hyperlipidemia (1996), Active

Chief Complaint:

Follow up for right knee pain on and off for about 3 months

History of Present Illness:

Mr. M. states, “My right knee has been hurting me on and off for 3 months now.” Mr. M. describes his pain as dull and start on the side and spreads over knee. He feels the pain when he is in the gym doing leg exercises or going up the stairs.  The pain remains for at least 1-2 hours after he does this activity then subsides on its own. He rates the pain as a 4/10 on a numeric scale but if he is just walking or laying down he has 0/10 pain. Mr. M. claims the pain becomes most severe when he is doing lunges and in the morning after arising. He also states the knee feels stiff in the morning but after an hour of waking up, “it feels back to normal.” Ice relieves the pain and he denies taking any over the counter medication. Mr. M. also denies any recent injury to the area. Osteoarthritis As An Inflammatory Disease Discussion Paper

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Past medical history:

Childhood illnesses: Unknown

Adult illnesses:

• Hypertension (1996)
• Hyperlipidemia (1996)

Past Surgical History: Not applicable

Allergies: Mr. D.P. has no known drug, environmental or food allergies.

Immunizations:

Mr. M. states he did receive the diphtheria, pertussis and tetanus vaccines during his childhood and his last tetanus booster was administered June 2014. Mr. M. has received the hepatitis B vaccine and the MMR vaccines (measles, mumps and rubella vaccines). Lastly, Mr. D.P. receives the influenza vaccine yearly.

Screening exams and Health Maintenance:

• PPD, 2014-negative
• HIV, 2008-negative
• Self-testicular exams, monthly-negative
• Colonoscopy, 2014-negative
• Annual physical with primary care provider

Medications:

• Just for Men multivitamin tablet– one tablet; once a day by mouth, for health maintenance
• Omega Fish Oil-one tablet; once a day by mouth, for health maintenance
• Atorvastatin 40 mg tablet– one tablet; once a day by mouth, for hyperlipidemia
• Losartan 50 mg tablet– one tablet; once a day by mouth, for hypertension

Family history:

• Father died at age 52 due to a myocardial infarction, had hyperlipidemia and hypertension.
• Mother died at age 72 due to cervical cancer, had hypertension and Rheumatoid arthritis.
• Sister is 71 years old, alive with hypertension, controlled with medications.
• Brother is 69 years old, alive with hypertension, diabetes mellitus type II and hyperlipidemia, controlled with medications. Osteoarthritis As An Inflammatory Disease Discussion Paper

Obstetric/Gynecologic: Not applicable

Personal and Social history:

Mr. M. is a 65 year old heterosexual Hispanic male. He works in maintenance, cleaning kitchens for the past 25 years and plans on retiring soon. Mr. M.’s highest educational level is high school. He lives with his wife in a condo in Bayside. He consumes alcohol, “Socially, about 6 eight ounce cans of beer a week.” He denies any use of tobacco, recreational drugs or prescribed medications. He also denies any use of assistive devices to get around or any help for activities of daily living.

Review of Systems:      

General– overweight male, denied fatigue, negative for fever or night sweats. Denied any recent weight gain/loss or any changes in appetite.

Skin– Negative for rashes, sores or recent changes in moles. Generalized hair thinning, nails negative for clubbing or cyanosis.

Head, Eyes, Ears, Nose, Throat

Head- Negative for headaches, lightheadedness, dizziness or head injuries.

Eyes-Denies double or blurry vision, discharge or itchiness. Endorses last eye exam to be 1 year ago, no history of scotoma, flashing lights, glaucoma or cataracts. Wear glasses to read.

Ears- Hearing good, negative for tinnitus, earaches, discharge, infections or use of hearing aids.

Nose and Sinuses– Negative sinus pressure or rhinorrhea. No history of hay fever, sinus infections, epistaxis or post nasal drip.

Mouth and Throat- Denies cough, no history of sore tongue, bleeding gums, strep throat or rheumatic fever. Positive history of caries and receding gums, no dentures, last dental exam 6 months ago.

Neck- negative for lymph nodes tenderness

Breast- No lumps, discharge, tenderness

Respiratory: Denied shortness of breath. Negative for history of chronic cough, wheezing, dyspnea or pleuritic chest pain. No cyanosis noted in nail beds or lips, negative tuberculosis test, 2014.

Cardiovascular: History of hypertension, controlled with losartan 50mg tablet, once a day. Hyperlipidemia controlled with atorvastatin 40mg tablet, once a day. Denied chest pain, palpitations, syncope, or congenital heart disease. Denies use of multiple pillows to sleep.

Peripheral Vascular – No history of deep vein thrombosis, edema lower extremities, varicose veins, claudication or leg cramps. Denies tenderness or swelling of finger tips or toes during cold weather.

Gastrointestinal- Denies nausea or vomiting. No history of hepatitis, hemorrhoids, tarry stools, rectal bleeding or jaundice. Regular bowel movements, at least once a day. Denies constipation or diarrhea.

Urinary-Positive nocturia x 1. Denies dribbling, polyuria or history of UTIs.  No history of dysuria or hematuria.

Genital- No history of sexual transmitted disease (last STD exam 2008). Denies testicular or scrotal pain, no history of sores or discharge from penis. Reports satisfactory sexual relations with only his wife and performs monthly testicular self-examinations.

Musculoskeletal- Positive right knee pain worse after exercises at gym. No history of broken bones, muscle injury or pain/stiffness in other joints. Denies gait imbalance or history of falls. Osteoarthritis As An Inflammatory Disease Discussion Paper

Neurologic- Endorses good memory. Negative loss of consciousness, seizures, memory changes.  Denies numbness, tingling or involuntary movements. Denies changes in attention, speech or judgment.

Hematologic- No history of anemia or transfusions, negative for blood disorders. Does not bleed or bruise easily.

Endocrine- No known thyroid or diabetes conditions. Denies cold or heat intolerance. Denies polyphagia, polyuria and polydipsia.

Psychiatric- Denies history of depression, anxiety, hallucinations, mania or mood changes. Denies suicidal ideation, no history of suicidal attempts or psychiatric hospitalizations.

Physical Exam:      

Vital signs- Blood pressure: 110/68, Heart rate: 64, Respirations: 13, Temperature: 36.8 degrees Celsius, Pulse ox: 98%. Weight 160 lbs., height 5’2 and BMI 29.

General– Mr. M. is an alert and oriented x3, overweight Hispanic male. Dressed appropriate for weather, clean clothes. Appropriate facial expressions and maintains eye contact.

Skin- Color is appropriate for ethnicity, warm and dry. Negative for rashes, sores or recent changes in moles. Approximately 8 to 10 scattered 2-3 cm round and symmetric macules with regular borders located on the upper chest area. Hair soft and generalized thinning. Nails pink and intact, non-pitting negative for clubbing or cyanosis.

HEENT:

Head: Normocephalic, scalp without lesions or deformities.

Eyes: Vision 20/25 bilaterally, pupils 4mm constricting to 2mm. Sclera white and conjunctiva pink, both are moist. No swelling or tenderness noted. Extraocular movements intact.  Disc margin sharp, without hemorrhages.

Ears: Wax mildly obscure tympanic membrane in right ear. Tympanic membranes with good cone of light. Acuity good to whispered voice, weber midline and AC>BC.

Nose: Nasal mucosa moist, septum midline and no sinus tenderness.

Mouth/Throat: Lips pink and moist. Tongue and uvula midline, gums moist and non-tender. No foul odor. Tonsils and pharynx non- erythematous, no exudate present.

Neck: Neck supple and easily moveable without resistance, trachea midline. Thyroid isthmus palpable, lobes not felt. No bruit auscultated.

Lymph nodes: Anterior cervical lymph nodes and posterior cervical lymph nodes soft, non-tender about 1 cm in size. Submandibular, submental, pre and post auricular, occipital, supraclavicular, axillary and epitrochlear nodes are non-palpable. Several small inguinal nodes palpated bilaterally, mobile, soft and non-tender.

Thorax and Lungs:  Posterior and anterior thorax symmetrical with good excursion. Lungs are clear, vesicular and resonant bilaterally. Negative for adventitious sounds. 13 respirations per minute.

Cardiovascular: Carotid artery upstroke normal bilaterally, without bruits. Jugular venous pressure is measured as 8 cm with patient at 30 degrees. Apical impulse discrete and tapping, barely palpable in 5^th left midclavicular interspace. Negative for thrills, heart rate regular, S1 and S2, no extra heart beats, murmurs or gallops. 64 heart beats per minute. Osteoarthritis As An Inflammatory Disease Discussion Paper

Breasts: No masses palpated, nipples without discharge.

Abdomen: Protuberant, symmetrical, no masses palpated. Bowel sounds active in all four, no masses or tenderness noted upon light/deep palpation.  Tympany upon percussion. No bruit auscultated. Liver span 7 cm in right mid clavicular lines, edge smooth, palpable. Spleen and kidneys non-palpable. No costovertebral angle tenderness, fluid waves or guarding noted.

Genitalia: not done; normal exam would demonstrate: External genitalia without lesions. Testicles descended bilaterally. Testes firm, non-tender, without masses or lesions. No penile lesions are noted and no discharge from urethra. Scrotum negative for induration or erythema. No hernias palpated in inguinal canals.

Rectal:  not done; normal exam would demonstrate: Normal rectal sphincter tone, rectal vault negative for masses, hemorrhoids, fissures, or tenderness.

Extremities: Warm, without edema. No cyanosis, tremors or clubbing noted. Joints are non-tender, full range of motion intact, negative swelling or deformities.

Peripheral Vascular: Peripheral pulses in femoral, popliteal, anterior tibial, dorsalis pedis, brachial and radial pulses are +2 bilaterally. No pigmentation or ulcers. Temperature of upper and lower extremities are warm bilaterally. Hair present and equally distributed in upper and lower extremities bilaterally.

Musculoskeletal: No joint deformities. Right knee pain +crepitus, equal range of motion to left knee but + tenderness upon active range of motion. Good range of motion in hands, wrists, elbows, shoulders, spine, hips and ankles. Spine has full range of motion, negative for lordosis or kyphosis, mobility intact.

Neurological: Alert and cooperative.

Mental Status: Coherent thoughts, oriented to person, place and time.

Cranial Nerves: CN I to XII intact

Motor: Good muscle bulk and tone, upper and lower strength 5/5 throughout extremities.

Cerebellar: Point to point, finger to nose, heel to shin, rapid alternating movement all intact. Gait stable, negative for ataxia.

Sensory: Pinprick, light touch, position sense, vibration and stereognosis intact. Romberg negative.

Reflexes: Normal and symmetrical deep tendon reflexes +2 bilaterally in all extremities including; biceps, triceps, patellar, achilles and plantar downward. Negative Babinski bilaterally.

Psychiatric: not done; normal exam would demonstrate mental status examination results were above normal with score of 29.

Laboratory date: last CBC and CMP are from December 2015 and lab values were all within normal limits. Blood pressure was well controlled and cholesterol levels were within normal range

October 2017:

• x-ray of right knee- demonstrated osteoarthritis
• RA Factor- negative
• CBC and CMP all within normal limits
  • Cholesterol: 190 mg/dl (below 200 mg/dl)
  • HDL: 62 mg/dl (above 60 mg/dl)
  • LDL: 156 mg/dl (below 150 mg/dl)
  • Triglycerides: 169 (below 150 mg/dl) Osteoarthritis As An Inflammatory Disease Discussion Paper

Differential diagnosis:

• Osteoarthritis
• Rheumatoid Arthritis
• Bursitis
• Fibromyalgia
• Facture/Dislocation
• Avascular Necrosis

Assessment Primary Diagnosis:

A 65-year old male with a primary medical history of hypertension and hyperlipidemia presents to the clinic complaining of right knee pain occurring “on and off,” for 3 months now. Upon examination, Mr. M. was able to move right knee against resistance and range of motion was equal to left knee but with tenderness during activity. Crepitus was also present during range of motion. Patient complains the pain has become progressively worse throughout the last 3 months and it is worse in the morning upon getting up from bed. He also mentions it subsides with rest and ice. Osteoarthritis symptoms typically present in the fourth and sixth decade and usually due to genetics, age, obesity or repetitive activities. (Buttaro et al., 2017). Mr. M. denies any recent injury to knee area. He also does not have any of these symptoms in any other joint.  X-rays done in October demonstrated, degeneration of cartilage, confirming osteoarthritis of the right knee.

Assessment and Plan:

• Osteoarthritis of Right Knee:
  1. X-ray of right knee (results demonstrated osteoarthritis)
  2. Check for Rheumatoid factor to rule out rheumatoid arthritis (results were negative) Osteoarthritis As An Inflammatory Disease Discussion Paper
  3. Take Tylenol 325 mg x 2 tablets every 6-8 hours as needed for pain. Continue ice packs which provide relief, 20 minutes on and off.
  4. Education provided on the importance of strengthening and stretching exercises.
  5. Referral for outpatient physical therapy (Buttaro et al., 2017).
• Hyperlipidemia:
  1. Continue taking Atorvastatin 40 mg tablet, once a day in the evening.
  2. Limit foods high in fat or fried (Fischer et al., 2015). Educate patient on what each meal plate should consist of by demonstrating the My Plate picture (United States Department of Agriculture, 2017).
  3. Engaging in regular aerobic exercise can increase HDL and decrease total cholesterol, LDL and triglyceride level (Buttaro et al., 2017).
• Hypertension:
  68. Patient’s blood pressure controlled at 110/68. He can continue with Losartan 50mg tablets, once a day.
  69. Patient is educated on the importance of consuming a low-sodium diet and increasing his consumption of fruits and vegetables. He will be referred to a dietician for further education regarding his diet. Patient is also educated on the importance of moderate exercise at least 30 minutes a day, 5 days a week.
  70. Education reinforced on signs and symptoms of high and low blood pressure. If patient does not experience any issues, he can follow up within a year for his blood pressure and EKG to be checked again.

Diagnostic Reasoning:

Mr. M. present with right knee pain occurring on and off for about 3 months. He describes the pain as dull and starts on one side and spreads over knee. Mr. M. states the pain becomes most severe when he is doing lunges and in the morning upon arising from bed. Ice relieves the pain and he denies taking any medication for it. He also denied any recent injury to the area or these similar symptoms in any other joints. Tenderness relieved with rest, stiffness worse in the morning and tenderness affecting one joint are all classic osteoarthritis symptoms that Mr. M. experienced (Berenbaum, 2013). In addition to these symptoms, the X-ray results confirmed the diagnosis of osteoarthritis.

Rheumatoid Arthritis (RA), is a chronic inflammatory disorder affecting many joints at the same time. Joints become red, swollen and tender. Anorexia, fatigue and weight loss also accompany RA. Mr. M. did experience tenderness but only in one joint and did not have any fatigue, anorexia or weight loss/gain (Buttaro et al., 2017). X-ray results confirmed osteoarthritis and his blood work came back negative for rheumatoid factor, therefore RA is ruled out. Osteoarthritis As An Inflammatory Disease Discussion Paper

Bursitis of the knee, also known as “housemaid knee,” due to excessive kneeling from carpentry, gardening or roofing (Buttaro et al., 2017). Tenderness is usually present at night and the bursa may feel rough like nodules. Swelling, edema may also be present if there is effusion in the joint. These symptoms are similar to what Mr. M. was experiencing but he denied any repetitive activity involving his knee, swelling or redness. In addition, his x-ray results demonstrated osteoarthritis which rules out bursitis.

Fibromyalgia is a disorder involving multiple body systems, mostly affecting the musculoskeletal system. Fatigue, altered sleep patterns, gastrointestinal complaints such as diarrhea or constipation are also symptoms experienced with fibromyalgia. Mr. M. did experience tenderness in joint but did not complain of fatigue, altered sleep patterns or GI issues that accompany fibromyalgia. Fibromyalgia is also ruled out because of the x-ray result demonstrating osteoarthritis (Buttaro et al., 2017).

Fracture is a complete or partial break in the bone while dislocation is when the joint is not in its designated area. Both fracture and dislocation are seen after trauma and are accompanied with extreme pain, deformity, limping, loss of functions and bruising (Buttaro et al., 2017).  Mr. M. denied any trauma and experienced tenderness and stiffness which is relieved with rest. The pain from a fracture or dislocation is severe and consistent until bone receives proper care, therefore fractures and dislocations are ruled out.

Avascular necrosis is death of the bone tissue due to lack of blood supply reaching the area. Symptoms that accompany avascular necrosis are tenderness, pain upon weight bearing, limping and collapsing. Eventually individuals who experiences avascular necrosis can complain of pain while simply laying down (Buttaro et al., 2017).  Mr. M. experiences pain relieved with rest but denied any limping or collapsing. Avascular necrosis is ruled out because the x-ray results demonstrate osteoarthritis. 

References

Berenbaum, F. (2013). Osteoarthritis as an inflammatory disease (osteoarthritis is not

osteoarthrosis!). Osteoarthritis and Cartilage, 21(1), 16-21.

Buttaro, T. M., Trybulski, J., Bailey, P., & Cook, J.. (2017). Primary Care: A Collaborative  

Practice. Canada: Elsevier.

Fischer, Schatz, & Julius. (2015). Practical recommendations for the management of

hyperlipidemia. Atherosclerosis (Supplements) (Component), 18, 194-198.

Lee, A. C., Harvey, W. F., Price, L. L., Han, X., Driban, J. B., Wong, J. B., & … Wang, C.

(2017). Mindfulness Is Associated With Treatment Response From Nonpharmacologic

Exercise Interventions in Knee Osteoarthritis. Archives Of Physical Medicine & Rehabilitation, 98(11), 2265-2273.e1. doi:10.1016/j.apmr.2017.04.014

United States Department of Agriculture: Choose My Plate (2017). SuperTracker: Food,

Physical activity and weight tracking. Retrieved from https://www.choosemyplate.gov/tools-supertracker.

This is a paper about a random Male patient which includes their health history and physical (it can be any MALE patient with any condition -completely made up). The format is posted below. Please follow the format and attached Genogram in the paper. I’ll upload the format and another assignment that was completed for me

Paper #1: First Written History and Physical: The Health History &Physical paper must include the following: a complete history of your patient’s background, a complete review of systems, and a complete physical exam.

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• Head-to-toe review of ALL systems
• Physical exam of the cardiovascular system
• Nutrition assessment
• Family history including a genogram.
• APA style

Paper 1 Grade Guideline:

Biographical Data
Points (Total 5) • Name (only initials), age
• Source of History (Who and reliability)

History of Present Illness 0,5 • Includes a chief complaint (Reason for seeing Care)
• Appropriate dimensions of cardinal symptom are listed – Location, Quality, Severity, Timing, Setting, chronology, aggravating/alleviating, associated manifestations)
• Incorporates elements of PMH, FH, SH that are relevant to the story (e.g. includes risk factors for CAD for patient with chest pain)
• ROS questions pertinent to the chief of complaint are included in HPI (not in ROS section)
• HPI narrative flows smoothly, in a logical fashion

Past Medical History 0.1 • Childhood Illness
• Accidents & Injuries
• Serious or Chronic Illness
• Hospitalizations

Past Surgical History 0.1 Includes approximate date, Surgeries, procedures, elective or non-elective, anesthesia given? What type of anesthesia—general, local etc.
Obstetric History (females) (with PMH) Use Gravida, Parity, Aborted, Living—G2P2 etc
• Last Menstrual Period

Immunizations 0.1 Childhood, Flu, Pneumonia, etc.

Allergies 0.1 Includes nature of adverse reactions

Medications 0.1 Includes dose, route and frequency for each medication
• Includes over the counter and herbal remedies

Family History 1.0
(including Genogram) • List medical conditions of parents, siblings, children, grandparents (GENOGRAM will be based on this***)
• Important diagnosis to look out: CAD, DM, HTN and Cancer
• Age at diagnosis (MI at what age? Etc), age of family members

Social History 0.5 • Occupation, Marital status
• Tobacco, Alcohol and Substance abuse; if they quit, how and when?
• Nutrition history
• Functional status (any assistive devices? Need help with ADLs?) and living situation (alone? In an assisted living?)
• Sexual Health- how do they define themselves? Are they sexually active? To whom? Any concern for HIV? STDs? Any use of protection?

Nutrition history
0.5 • Nutrition history

Review of System
1.5 • Body systems are evaluated: Constitutional/General, Skin, HEENT, Respiratory, Cardiovascular/Peripheral Vascular, GI, GU, Muscular, Neuro, Psych, Hematologic/Lymph, Endocrine
• Should NOT include PMH (ex. Cataracts or murmur of the heart belong in PMH, NOT ROS)
• Should NOT repeat information already in HPI
• Should NOT include Physical Exam findings Osteoarthritis As An Inflammatory Disease Discussion Paper
• Should INCLUDE adequate depth (be very thorough, in full sentences!)
• NO USE OF “NORMAL” is Allowed

Style 0.5 • Legible
• Not laden with spelling or grammatical errors
• Uses medical abbreviations appropriately, does not “coin” own abbreviations
• APA style, typed, double spaced with COVER PAGE

FORMAT TO FOLLOW (please add genogram)

GENERAL INFORMATION
Patient Name (initials only): Name/Initials of Examiner:
Gender: Source of Referral:
Source of History/Reliability: Date:

PROBLEM LIST (list active and inactive diagnoses)

CHIEF COMPLAINT (CC): “quote patient”
HISTORY OF PRESENT ILLNESS (HPI): Presenting signs & symptoms, duration of same, pertinent history relevant to the chief complaint. Include 7 attributes—location, quality, quantity/severity, timing–including onset/duration, & frequency, setting in which it occurs, factors aggravating or relieving symptom, associated manifestations

PAST CHILDHOOD ILLNESSES: i.e. measles, mumps, rubella, varicella, scarlet fever, rheumatic fever, polio, and any other childhood illnesses such as Asthma (include dates)
PAST MEDICAL HISTORY (PMH): dates in reverse chronological order.
PAST SURGICAL HISTORY (PSH): surgical dates in reverse chronological order.

ALLERGIES: medications, OTCs, supplements, & environmental/seasonal/food allergies
UNTOWARD MEDICATION REACTIONS: include type of reaction/severity/date
IMMUNIZATION STATUS: e.g. Flu, Prevnar 13, TdaP, etc..Date must be included
SCREENING TESTS: e.g. colorectal screening, mammogram, pap test, PSA, etc…
FAMILY HISTORY: include relevant genetic risk history for living/deceased immediate relatives including grandparents, parents, siblings, children, grandchildren; for deceased relatives include cause of death and age; for sick relatives include age of onset
PERSONAL/SOCIAL: marital status, children, occupation, living arrangements, exercise, personal interests, religion, tobacco—use in pack years, if stopped smoking for how long did they smoke and when did they quit smoking; alcohol use—how many drinks/week, type of alcohol
FEMALES: LMP and relevant OB/GYN history Gravida, Para, Abortions-spontaneous vs. induced: age of menarche, menopause.
SEXUAL HISTORY: #of partners, sex of partner/s, protected/unprotected sexual relations, contraception

MEDICATIONS: dose, route, frequency (write class of medication in parentheses): Osteoarthritis As An Inflammatory Disease Discussion Paper

Review of Systems:
General:
Skin:
HEENT:
Head:
Eyes:
Ears:
Nose:
Throat:
Breasts:
Respiratory:
Cardiovascular:
Gastrointestinal:
Genitourinary:
Peripheral Vascular:
Musculoskeletal:
Neurologic:
Hematologic: Osteoarthritis As An Inflammatory Disease Discussion Paper