York College- Physician Assistant Program

Physical Diagnosis 1, Spring 2022

H&P

Heba Fakir

History:
Identifying Data:
Full Name: Mr. AC

Address: Glendale, NY

DOB: June 26, 1958

Date & Time: February 2, 2022

Location: NYPH, Flushing, NY

Religion: Catholic

Source of Information: Self

Reliability: Reliable

Source of Referral: Primary Care Physician (unable to recall name or information)

Chief Complaint: “Really bad left ear pain” x 2-3 days.

History of Present Illness

64 y/o M with PMH of A Fib (on Eliquis), T2DM, and HLD presents to ED with c/o L ear pain x 2-3 days. He describes it as L sided painful ear pressure (with a pain scale of 8/10). Pt notes the pain also radiates to his L Temporal Bone and he has associating symptoms of “milky white” discharge from L ear, dizziness, and unsteadiness in gait. He states there wasn’t any factor that made it worse and he has not taken any medications to alleviate the ear pain. 

Pt states he has been having recurrent otitis media since 2020, and he was hospitalized for it in 2021. Pt notes he can’t hear anymore from his L side since then. He also reports he poked his L ear with a toothpick as a child, which he later had “an ear operation” for in 1973.

Denies HA, fever, chills, nausea, vomiting, syncope, blood discharging from both ears, and vision disturbances.

Past Medical History:
1) Atrial Fibrillation (dx 10 yrs ago, on Eliquis)

2) T2DM (dx in 2003)

3) Benign Prostate Hyperplasia (dx 5 yrs ago)

4) Hyperlipidemia (dx 10 yrs ago)

Childhood Illnesses- Polio (as a child)

Denies other illnesses including HTN, Asthma, and COPD.

Immunizations- Up to date, last flu vaccine in 2021

Past Surgical History

Ear Operation in 1973 at New York Eye and Ear Infirmary

Lumbar Disc Herniation Surgery in 1997

Percutaneous Nephrolithotomy in 12/2021

Medications

1) Insulin Lantus (Glargine) 8u QPM for T2DM

2) Insulin Humalog (Lispro) 5u ac meals for T2DM

3) Toprol XL (Metropolol Tartate) 12.5 mg BID for A Fib

4) Pravachol (Pravastatin) 20 mg QPM for HLD

5) Cartia XT (Diltiazem) 60 mg every 8 hrs for A Fib

6) Eliquis (Apixaban) 5 mg BID for A Fib

7) Flomax (Tamsulosin) 0.4 mg QD for BPH

8) Baby Aspirin 81 mg QD for Cardioprotective

Allergies:
NKDA

Denies environmental or food allergies.

Family History:

Mother:

Pt is unaware of mother’s PMHx

Deceased at age 87, from CVA

Father:

Hx of HLD

Deceased at 64 from PNA

Older Sister:

Hx of T2DM and CKD

Social History:

Living Situation: Mr. AC is a married retired male and lives with his wife.

Alcohol Use: Pt denies drinking.

Smoking: Pt denies past and present hx of tobacco use.

Illicit Drugs: Pt denies past and present hx of illicit substance use.

Diet: Pt has a balanced diet.

Sexual History: Heterosexual, monogamous, and uses barrier protection.

Pt denies hx of STI.

Pt denies any recent travels.

Review of Systems

General

Pt admits to chills, night sweats, fatigue, and recent weight loss of 2-3 lbs in 1 week.

Denies loss of appetite, fever, and weakness.

Skin, Hair, and Nails

Pt admits to having skin hyperpigmentation on BUE “all his life.”

Denies skin discolorations, moles/rashes, pruritus, changes in skin texture, excessive dryness, swelling, and changes in hair distribution.

Head

Denies headache, vertigo, lightheadedness, head trauma, and LOC.

Eyes

Last Eye Exam: in 11/2021

Pt admits to wearing reading glasses but not contacts

Denies blurry vision, diplopia, fatigue with use of eye, scotoma, halos, lacrimation, photophobia, and pruritus.

Ears

Pt admits to L ear pain, L ear discharge, and L ear deafness (he denies using hearing aids).

Denies tinnitus.

Nose/Sinuses

Pt admits to random episodes of nasal discharge that’s milky white but not related to his ear pain.

Denies epistaxis.

Mouth and Throat

Last Dental Exam: in 2021

Denies bleeding gums, sore tongue, sore throat, mouth ulcers, voice changes, and using dentures.

Neck

Denies localized swelling/lumps, and stiffness/decreased range of motion.

Breast

Denies lumps, nipple discharge, breast pain.

Pulmonary System

Denies SOB, DOE, cough, wheezing, hemoptysis, orthopnea, cyanosis, and PND.

Cardiovascular System

Pt admits to syncope during his 1^st episode of ear infection in 2020.

Denies palpitations, irregular heartbeat, edema/swelling of ankles or feet, and known heart murmur.

Gastrointestinal System

Denies changes in appetite, nausea, vomiting, intolerance to specific foods, dysphagia, pyrosis, flatulence, eructation, abd pain, diarrhea, jaundice (dark urine and light clay colored stool), changes in bowel habits, hemorrhoids, constipation, rectal bleeding, and melena. 

Genitourinary System

Last Prostate Exam in 2021

Denies urinary frequency, nocturia, urinary urgency, oliguria, polyuria, dysuria, changes in color of urine, urinary incontinence, and flank pain.

Nervous System

Denies seizures, headache, LOC, sensory disturbances (numbness, paresthesia, dysesthesias, hyperesthesias), ataxia, loss of strength, changes in cognition/mental status/memory, and weakness.

Musculoskeletal System

Denies muscle/joint pain, deformity, redness, and arthritis.

Peripheral Vascular System

Denies intermittent claudication, coldness or trophic changes, varicose veins, peripheral edema and color change.

Hematologic System

Pt admits to bruising easily.

Denies anemia, easily bleeding, lymph node enlargement, hx of PE, and hx of DVT.

Endocrine System

Denies polyuria, polydipsia, polyphagia, heat/cold intolerance, goiter, diaphoresis and hirsutism.

Psychiatric

Denies depression/sadness, anxiety, obsessive/compulsive disorder, and taking psychiatric medications.

Vital Signs

BP	R	L
Seated	110/76	115/74
Supine	110/72	118/76

R: 18 breaths/min unlabored regular rhythm

P: 80 BPM regular

T: 98.6 Degree F (Oral)

O2 Sat: 98% Room Air

Height: 66 inches

Weight: 140 lbs

BMI: 22.59 

Skin, Head Examinations

Skin: Small 1-2cm Diffuse Circumscribed Brown Hyperpigmented Macules on the R and L arm, Non-blanching, Warm & Dry, Good Turgor, No Tattoos

Hair: Male Pattern Baldness, Short Gray Hair

Nails: Capillary Refill less than 2 seconds, no clubbing, no Koilonychia, no Beau’s Line, no Splinter Hemorrhage, no Paronychia 

Head: Tender to palpation at L Temporal Lobe. Normocephalic, symmetric, atraumatic, and no facies.