York College- Physician Assistant Program

Physical Diagnosis 2, Fall 2022

H&P

Heba Fakir

History:
Identifying Data:
Full Name: Mr. KC

Address: Queens, NY

DOB: April 4, 1959

Date & Time: September 20, 2022

Location: NYPH, Queens, NY

Religion: Christian

Source of Information: Self

Reliability: Reliable

Source of Referral: Self

Chief Complaint: “Here for a check up before my kidney surgery in 13 days.”

History of Present Illness:

63 y/o M with PMHx of recurrent nephrolithiasis presents to preadmission testing for his scheduled B/L Ureteral Stenting on 10/3/22. Pt states he had 3 episodes of nephrolithiasis since 2019 which he was able to pass. However, he reports on 8/12/22 when he watching tv he had an acute onset of R dull flank (8/10) constant pain which eventually radiated to his RUQ.

He states he also developed body chills. Pt notes his sx worsened with any movement and was alleviated for 4-5 hours when he took 2 pills of ASA 325mg. Pt went to the ER and a CT scan was done which showed B/L Ureteral Stones (R Ureteral Stone 7mm and L Ureteral Stone 6mm). Pt denies fever, nausea, vomiting, dysuria, anuria, oliguria, hematuria, pyuria, foamy urine, polyuria, nocturia, urinary frequency, urinary urgency, urinary incontinence, weight loss or gain, fatigue, night sweats, loss of appetite, bone pain, muscle weakness, polydipsia, flank trauma, constipation, edema, rash, palpitations, fatigue, dizziness, and lightheadedness.

Past Medical History:
Recurrent Nephrolithiasis (since 2019)  

BPH (dx in 2019)

Past Hospitalizations:

Pt denies any past hospitalizations.

Pt denies any hx of blood transfusions.  

Childhood Illnesses: Unremarkable.

Immunizations: Pt is UTD on COVID-19, Flu, and Pneumococcal Vaccine. 

Past Surgical History:

R Achilles Tendon Repair (in 2008)

Medications:

Aspirin (ASA) 325 mg PO prn for pain

Flomax (Tamsulosin) 0.5 mg PO QD for BPH

Allergies:
NKDA

Pt denies any food allergy and environmental allergies.

Family History:

Mother:

Pt is unsure.

Father:

Atherosclerosis Cardiovascular Disease.

Paternal Grandparents:

Pt is unsure.

Maternal Grandparents:
Pt is unsure.

Social History:

Living Situation: Pt works as an aircraft mechanic and lives with his wife.  

Alcohol Use: Pt denies.

Smoking: Pt denies.

Recreational Drugs: Pt denies.  

Diet: Pt eats 2 meals QD which consists of vegetables and around 50 g of protein. He states he snacks on fruits.

Exercise: Pt uses the treadmill (low intensity) once in a while.

Sleep: Pt states he sleeps ~4-5 hrs every night.

Sexual History: Pt is sexually active. He is heterosexual and monogamous. Pt does not use condoms.

Pt denies hx of STI.

Review of Systems

General

Admits to chills.

Denies fatigue, weight loss/gain, loss of appetite, fever, night sweats and weakness.

Skin, Hair, and Nails

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

Head

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

Eyes

Last Eye Exam: in 2020.

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

Ears

Admits to diminished hearing in R ear and B/L tinnitus.

Denies deafness, pain, discharge and using hearing aids.

Nose/Sinuses

Denies epistaxis, discharge, and obstruction.

Mouth and Throat

Last Dental Exam: 3 weeks ago.

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

Neck

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

Breast

Denies lumps, nipple discharge, and breast pain.

Pulmonary System

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

Cardiovascular System

Denies CP, HTN, palpitations, irregular heartbeats, syncope, edema/swelling of ankles/feet, and having any known heart murmur.

Gastrointestinal System

Pt admits RUQ Abd Pain.

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

Genitourinary System

Pt admits to R Flank Pain.

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

Nervous System

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

Musculoskeletal System

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

Peripheral Vascular System

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

Hematologic System

Denies easily bruising/bleeding, anemia, blood transfusions, 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, taking psychiatric medications, and h/o seeing a psychiatrist.

Vital Signs

BP	R	L
Seated	131/78	129/79
Supine	128/75	127/77

R: 16 breaths/min unlabored regular rhythm

P: 74 BPM regular

T: 36.4 Degree C (Oral)

O2 Sat: 100% Room Air

Height: 170.2 cm

Weight: 75.75 kg

BMI: 26.1 

General Survey

Pt appears in no acute distress, well groomed, and well nourished. Appears stated age. Awake, A&O x 3.

Skin and Head Examination

Skin: Skin is warm & moist, good turgor, nonicteric, no lesions noted, no scars, no tattoos.

Hair: Short white hair with average quantity and distribution.

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

Head: Normocephalic, no facies, atraumatic, non-tender to palpation throughout.

Eye Examination

Eyes:

Symmetrical OU. No strabismus, exophthalmos, no ptosis. Sclera white, anicteric, cornea clear, and conjunctiva pink.

Visual Acuity Corrected: 25/25 OS, 25/25 OD, 25/25 OU.

Visual Fields Full OU. PERRLA. EOMs intact with no nystagmus.

Fundoscopy: Red Reflex Intact OU. Cup to disk ratio less than 0.5 OU. No AV nicking OU, no hemorrhages OU, no exudates OU, no neovascularization OU, no cotton wool patches OU.  

Ear, Nose, and Sinus Exam

Ear: symmetrical and appropriate in size. No lesions, no masses, no trauma, and nontender to palpation on external ears. No discharge, no foreign bodies in external auditory canals AU. TMs pearly white and intact with light reflex in good position AU. Auditory acuity diminished in R ear but intact in L ear to whispered voice. Weber localizes to R ear. Rinne Reveals BC > AC in R ear and AC > BC in L ear.

Nose: symmetrical, no masses, no lesions, no deformities, no trauma, no discharge, nares patent B/L, nasal mucosa pink and well hydrated, no discharge noted on anterior rhinoscopy. Septum midline without lesions, no deformities, no injection, no perforation. No foreign bodies.

Sinuses: Non-tender to Palpation over B/L Maxillary, B/L Ethmoid Sinuses, B/L Frontal Sinuses.

Mouth, Pharynx, and Neck Exam

Lips: pink, moist, no cyanosis, no lesions, no fissures, nontender to palpation, no Fordyce Spot.

Mucosa: pink, well hydrated, no masses, no lesions, no Leukoplakia, no Oral Candidiasis, no Aphthous Ulcer.

Palate: pink, well hydrated, palate intact, no lesions, no masses, no Palatine Torus, no Mandibular Torus, no scars.

Teeth: good dentition, no obvious Dental Caries.

Gingivae: pink, moist, no Gingival Hyperplasia, no Gum Recession, no masses, no lesions, no erythema.

Oropharynx: well hydrated, no injection, no exudate, no masses, no lesions, no foreign bodies, tonsils present (Grade 1) with no injection or exudate. Mallampati Class I. Uvula mid line and symmetrical with no deviation and no lesions.

Neck: trachea midline, no masses, no scars, no lesions, no pulsations noted, nontender to palpation. No stridor noted, 2+ carotid pulses, no thrills; no bruits noted B/L, no cervical adenopathy.

Thyroid: non-tender, no palpable masses, no thyromegaly, no bruits noted.

Thorax & Lungs Exam

Chest: Symmetrical, no deformities, no trauma. Respirations unlabored, no paradoxical respirations, no accessory muscle use noted. Lat to AP Diameter 2:1. Nontender to palpation throughout.

Lungs: No adventitious sounds, clear to auscultation and percussion B/L. Chest expansion and diaphragmatic excursion symmetrical. Tactile fremitus symmetric throughout.

Cardiac Exam

Heart: JVP is 2cm above sternal angle with head of bed at 30 degree. PMI in 5^th ICS in mid-clavicular line. Carotid Pulses are 2+ B/L without bruits. RRR. S1 and S2 are distinct with no murmurs, S3 or S4. No splitting of S2 or friction rubs appreciated.

Breast Exam

Breast: Symmetric, no dimpling, & no masses to palpation. Nipples symmetric without discharge or lesions. No axillary nodes palpable.

Abd Exam

Abd: R Flank Tenderness and R CVA Tenderness. Non-tender to palpation. Negative Psoas sign, negative Obturator sign, negative Rovsing sign, negative Murphy’s sign, negative rebound tenderness, no B/L palpable flank masses, and negative guarding. Abd is flat soft symmetric with no striae. No scars, no masses, no lesions, no hernia, and no pulsations noted. Bowel Sounds normoactive in all 4 quadrants with no aortic/renal/iliac or femoral bruits. Tympanic throughout and no hepatosplenomegaly to palpation.

Male Genitalia & Hernias

Genitalia & Hernia: Circumcised male. No penile discharge or lesions. No scrotal swelling or discoloration. Testes descending B/L, smooth and without masses. Epididymis nontender. No inguinal or femoral hernias noted.

Anus, Rectum, & Prostate

Anus, Rectum, & Prostate: Prostate is enlarged with soft, smooth, and nontender surface. R lobe is larger (4.7 cm x 4.21 cm, 30 cc). No perirectal lesions or fissures. External sphincter tone intact. Rectal vault without masses. Stool brown and Hemoccult negative.

Differential Diagnoses

1. Nephrolithiasis: Pt’s story of the sudden onset of R Flank pain along with his history of recurrent nephrolithiasis points in the direction of another attack.
2. Pyelonephritis: Pyelonephritis is a possibility since pt has R flank pain, R CVA tenderness, and chills. On the other hand, pt does not have fever, pyuria, or dysuria.
3. Cholecystitis is a possibility since pt had constant severe pain at RUQ, however, it is unlikely since Murphy sign was negative and pt did not have sx of nausea, vomiting, nor fever.
4. Adult Polycystic Kidney Disease: its possible with patient’s history of recurrent nephrolithiasis along with the abd & flank pain. But unlikely, since he does not have symptoms of UTI or hematuria and there was no palpable flank masses.
5. Acute Glomerulonephritis: is also possible with the flank pain, but unlikely as pt does not have hematuria, fever, oliguria, or edema.

Assessment

63 y/o M with PMHx of recurrent nephrolithiasis presents to preadmission testing for evaluation of B/L Ureteral Stenting scheduled for 10/3/22. His initial presenting symptom of R flank pain 1 month ago is most consistent with nephrolithiasis.

Plan

1. B/L Ureteral Stones: Place Ureteral Stents. Pt will receive a phone call from the surgeon the day before regarding time of surgery and anesthesia options.
2. BPH: continue Flomax (Tamsulosin) 0.5 mg PO QD for BPH.
3. c/o diminished hearing and tinnitus: Refer pt to PCP for continued workup. PE showed auditory acuity diminished in R ear, but intact in L ear to whispered voice. Weber localizes to R ear. Rinne Reveals BC > AC in R ear and AC > BC in L ear.