Identifying Data:

Date and Time: 11/26/19, 8:30AM 

Location: New York Presbyterian Queens 

Full Name: SG

Age: 60 y/o 

Date of Birth: 5/17/1959

Sex: Female

Race: African American 

Nationality: American

Address: Queens

Marital Status: Married

Religion: Catholic

Source of Information: Patient 

Reliability: Patient is a reliable source 

Source of Referral: Urologist

Mode of Transport: private 

Primary Care Physician: Dr. Somogyi 

Chief complaint:“I have been having blood in my urine x2 months.” 

History of Present Illness: 

Patient is a 60 y/o African American reliable female, with a history of lupus, HTN, a bladder stimulator and a bladder obstruction, who presents to preadmission testing c/o gross hematuria for two months, with a scheduled cystoscopy for 12/4/19. Patient states she started to notice constant gross hematuria two months ago and reports having a cystoscopy with opening of her bladder blockage 1.5 months ago, which provided relief for approximately five weeks. Patient states prior to this, she has had intermittent hematuria for the last three years and has had two previous cystoscopies with normal biopsies in the past, but reports she is having another biopsy during this cystoscopy. She denies any other modifying factors and denies taking medication for the pain. Patient also reports urinary urgency, frequency, decreased urinary output and 4/10 dysuria but denies fever, chills, nausea, vomiting, abdominal pain or any other symptoms at this time. She states her symptoms are affecting her everyday life because she has to wear adult diapers and constantly feels as if she must be near a restroom in case she has to urinate. 

Past Medical History: 

Present medical illnesses: Lupus x unknown amount of time 

                                      Hypertension x unknown amount of time 

                                     Osteoarthritis in back x unknown amount of time 

Past medical illnesses: Pericarditis, treated and resolved in 2004 

                                     Lupus nephritis, resolved unknown year 

Childhood illnesses: Denies childhood illnesses 

Immunizations: Influenza shot in one month ago. No pneumococcal vaccination    

Past Surgical History: 

Partial hysterectomy due to uterine fibroids with no complications, 1997 New York Presbyterian Queens 

Bladder stimulator placement due to urinary incontinence with no complications, 01/2019, NY Presbyterian Queens  

Carpal Tunnel Surgery due to carpal tunnel in right hand, 2014, NY Presbyterian Queens

Injury: Fractured right hand due to a mechanical fall, 2017, NY Presbyterian Queens  

Denies other surgeries, other injuries or transfusions 

Medications:

Diltiazem, 300mg, 1 tab PO daily in morning, last dose this morning for blood pressure

Metoprolol, 25mg, 1 tab PO daily in morning, last dose this morning for blood pressure

Plaquenil, 100mg, 1 tab PO daily in morning, last dose this morning for lupus 

Tramadol, 50 mg, 1 tab take as needed,unknown last dose, for pain 

Allergies:

Cozaar – coughing 

No known food, environmental or other medication allergies 

Family History: 

Paternal grandfather – unknown history

Paternal grandmother – deceased due to kidney failure at unknown age 

Maternal grandfather – deceased due to prostate cancer in late 80s 

Maternal grandmother – deceased due to cervical cancer at unknown age 

Mother – deceased at 62 due to MI s/p angioplasty, HTN and angina  

Father – deceased at 64 due to MI  

Patient has six sisters and seven brothers, but does not know their ages and specific histories 

Daughter – 32, alive and well

Denies family history of allergies, gastrointestinal diseases, lung disease, endocrine disorders, psychiatric or nervous disorders

Social History: 

SG is a married, retired female who lives at home with her husband. 

Habits: Denies alcohol, tobacco, illicit drug or caffeine use.  

Travel: She reports traveling to Mexico Oct. 9-13^th

Diet: Patient typically eats carbohydrates and fish. States she does not eat meat.  

Sleep: Patient does not sleep well at night, 4 hours a night.

Exercise: Patient walks daily and plays with her grandchildren multiple times a week. 

Safety: Admits to wearing a seatbelt while driving. 

Review of Systems: 

General –Admits to fatigue. Denies fever, chills, recent weight loss or gain, loss of appetite, generalized weakness 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 a nonradiating, gradual, every other day headache. *Should ask further OLDCARTS* Denies current vertigo or head trauma.

Eyes – Denies blurry vision, diplopia, fatigue with use of eyes, scotoma, halos, lacrimation, photophobia, pruritus. Last eye exam five months ago. Wears glasses.

Ears – Denies deafness, pain, discharge, tinnitus or use of hearing aids.

Nose/sinuses – Denies discharge, obstruction or epistaxis.

Mouth/throat – Denies bleeding gums, sore tongue, sore throat, mouth ulcers, voice changes or use of dentures. Last dental exam three years ago, normal. 

Neck – Denies localized swelling/lumps or stiffness/decreased range of motion

Breast – Denies lumps, nipple discharge, or pain. Last mammogram one year ago, WNL.  

Pulmonary system –   Admits to monthly cough. Denies dyspnea, dyspnea on exertion, wheezing, hemoptysis, cyanosis, or paroxysmal nocturnal dyspnea (PND) or orthopnea.

Cardiovascular system – Admits to hypertension and known heart murmur. Denies palpitations, irregular heartbeat, edema/swelling of ankles or feet or syncope. 

Gastrointestinal system – Admits to loss of appetite and reports increased BM after bladder blockage removal last month. Denies nausea, vomiting, abdominal pain, intolerance to specific foods, dysphagia, pyrosis, hematemesis, unusual flatulence or eructation, diarrhea, jaundice, hemorrhoids, constipation, rectal bleeding or blood in stool. Last colonoscopy few years ago. 

Genitourinary system – Admits to urinary frequency, urgency, dysuria, incontinence and hematuria. Denies nocturia, oliguria, polyuria, awakening at night to urinate or flank pain. 

Sexual history – patient is sexually active with one male, her husband. Patient denies using protection or contraception. She reports getting Trichomoniasis several times since she was 18 y/o, with her last treatment one year ago. Patient denies anorgasmia. 

Menstrual/Obstetrical – Menarche age 16. LMP in 1997 prior to hysterectomy. Denies postcoital bleeding, vaginal discharge or dyspareunia. Patient in menopause, does not know date of cessation and denies associated symptoms. G2P1001. 

Nervous – Admits to numbness. Denies dizziness, seizures, headache, loss of consciousness, sensory disturbances, ataxia, loss of strength, change in cognition / mental status / memory, or weakness. 

Musculoskeletal system – Admits to muscle/joint pain, swelling of hands, redness and arthritis. Denies deformities. 

Peripheral vascular system – Denies intermittent claudication, coldness or trophic changes, varicose veins, peripheral edema or color changes.

Hematological system – Admits to anemia. Denies easy bruising or bleeding, lymph node enlargement, blood transfusions, or history of DVT/PE.

Endocrine system – Denies polyuria, polydipsia, polyphagia, heat or cold intolerance, excessive sweating, hirsutism, or goiter

Psychiatric – Denies anxiety, depression/sadness, OCD or ever seeing a mental health professional or taking medications for mental health

Vital Signs: 

Blood pressure: 

Sitting:             R 170/98         L 180/90

Lying down:     R 160/98         L 176/102

Pulse: 55 bpm, regular 

Respiratory Rate: 16 breaths/minute, unlabored 

Temperature: 98.2 degrees F orally

O2 sat: 96% room air  

Height: 5’ 4”

Weight: 178lbs

BMI: 30.55

General Survey: Obese female, well-groomed and in no apparent distress. Alert and oriented. 

Skin:Warm & moist, good turgor. Nonicteric, no lesions noted, no scars, tattoos.

Hair: Average quantity and distribution 

Nails: No clubbing, capillary refill <2 seconds throughout 

Head: Normocephalic, atraumatic, nontender to palpation throughout 

Eyes: symmetrical OU. No evidence of strabismus, exophthalmos or ptosis; scelra white, conjunctiva and cornea clear. 

Visual acuity: corrected 20/200 OS, 20/200 OD, 20/30 OU. Full visual fields OU. PERRLA. EOMs full with no nystagmus. 

Fundoscopy: Red reflex intact OU. Cup to disc ratio less than 0.5 OU. No evidence of A-V nicking, papilledema, hemorrhage, exudate, cotton wool spots or neovascularization OU. 

Ears: Symmetrical and normal size. No lesions/masses / trauma on external ears. No discharge / foreign bodies in external auditory canals AU. Cerumen and flakiness in external auditory canal AD.  TM’s pearly white, intact with light reflex in normal position AU .Auditory acuity intact to whispered voice AU. Weber midline/Rinne reveals AC>BC AU. 

Nose: Symmetrical, no masses, lesions, trauma or discharge. Nares patent bilaterally. Septum midline without lesions, deformities, injection, perforation. Nasal mucosa pink and well hydrated. No discharge noted. No foreign bodies.

Sinus: Nontender to palpation and percussion over bilateral frontal and maxillary sinuses. 

Lips: Pink, moist, no cyanosis or lesions. 

Mucosa: Pink, well-hydrated. No masses or lesions. No leukoplakia. 

Palate: Pink, well-hydrated. Palate intact with no lesions, masses or scar. 

Teeth: Dentition with multiple filled caries and missing teeth. No loose teeth. 

Gingivae: Pink, moist. No hyperplasia, masses, lesion, erythema or discharge. 

Tongue: Pink, well-papillated. No masses, lesions or deviations. Non-tender to palpation. 

Oropharynx: Well hydrated. No injection, exudate, masses, lesions, foreign bodies. Tonsils present with no injection or exudate. Uvula pink, no edema or lesions. 

Neck: Trachea midline. No masses, lesion, scars. FROM. No palpable adenopathy noted.

Thyroid: Non-tender, no palpable masses, no thyromegaly. 

Chest: Symmetrical, no deformities, no evidence trauma.  Respirations unlabored. No paradoxic respirations or use of accessory muscles noted.  Lat to AP diameter 2:1. Non-tender to palpation. 

Lungs: Clear to auscultation and percussion bilaterally.   Chest expansion and diaphragmatic excursion symmetrical.   Tactile fremitus intact throughout.  No adventitious sounds.

Abdomen: Abdomen flat and symmetric with no scars, striae or pulsations noted.  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. 

Heart: JVP is 2.5 cm above the sternal angle with the head of the bed at 30°. PMI in 5^thICS in mid-clavicular line.  Carotid pulses are 2+ bilaterally without bruits. Regular rate and rhythm. S1 and S2 are distinct, unable to appreciate patient’s murmur. No splitting of S2 or friction rubs appreciated.