Patient Initials and age: RS, 81
DATE OF SERVICE: September 20, 2013
Chief Complaint: “bladder pain,” and annual wellness exam.
History of Present Illness: Patient presents today with the complaints of bladder pain and for her annual wellness visit. The patient states the pain comes and goes, sometimes feeling like a burning sensation and other times as a sharp pain. The patient has a history of receiving bladder surgery with a sling, “years,” ago which she states has been having recurrent UTI’s and bladder pain ever since the surgery. The patient states the bladder surgery was by her current OBGYN. She states she does feel as though she empties her bladder completely with each urination. She does report a foul odor to her urine, frequency, and urinary stress incontinence. She denies any fever, chills, sweats, nausea, vomiting, vaginal itching or discharge, hematuria, or changes to her urine color. The patient states she drinks large amounts of water and green tea. Patient states cannot recall any particular aggravating or alleviating factors to the pain other than the actual pain with urination.
Past Medical History:
1. Cervical cancer
2. Total hysterectomy
3. Left ventricular hypertrophy
4. Hypertension
5. Hemorrhoids
6. Osteoarthritis
7. Edema
8. Tinnitus
9. Onychomycosis
10. Bladder surgery with sling
11. Insomnia
12. Gastroesophageal reflux disease
13. Hypothyroidism
Family History:
1. Father deceased at age 92 with cardiac disease
2. Mother deceased in her 60’s of cancer
3. One brother deceased at age 84 with cardiac disease
4. Second brother deceased at age 60 with cardiac disease
5. One sister deceased in her 50’s with cardiac disease
6. Two other sisters deceased with strokes
7. One son with diabetes and hypertension
8. Two other children healthy and living
Social History:
1. Tobacco use, quit smoking 43 years ago
2. Denies alcohol use
3. Moderate caffeine intake. Patient states drinks moderate amounts of green tea
4. Exercises several times a week at home
5. Married
6. Denies multiple sex partners
7. Denies illegal drug use
Allergies: Patient has no drug, environmental, or food allergies
Current Medications:
1. Synthroid, 100 mcg P.O daily
2. Lasix 20 mg P.O. daily
3. Multivitamin one P.O. daily
4. Vitamin D OTC, one P.O. prn
5. Temazepam 15 mg P.O. daily
6. Omeprazole 40 mg P.O. prn
Immunization Status:
1. Influenza vaccine: 2012
2. Pneumonia vaccine: Up to date
3. Tetanus vaccine: Up to date
4. Patient unable to report immunization history other than listed above
Review of Systems:
General: denies any fever, chills, malaise, night sweats, or any recent weight loss or gain.
Head, Ears, Eyes, Nose, Mouth, and Neck: denies any headaches, dizziness, visual loss, blurred vision, double vision, history of concussions, nose bleeds, ear infections, light sensitivity, history of glaucoma or cataracts, difficulty swallowing, throat swelling, or any throat, ear, or nasal pain. Patient does wear reading glasses, wears upper and lower dentures, and states she routinely sees an ophthalmologist. She also reports a history of tinnitus.
Lymphatic: denies any enlarged, reddened, or tender lymph nodes.
Integumentary: denies any rashes, changes to moles, easy bruising, itching, excessive sweating, or bites. Patient does report dry skin, having several fatty lipomas, and fungal infection to right great toe.
Chest/ Respiratory: denies any cough, wheezing, shortness of breath, sputum, sleep apnea, painful breathing, hemoptysis, night sweats, or exposure to tuberculosis. Patient does not recall ever having a TB skin test.
Cardiac: denies any chest pain, palpitations, dyspnea, orthopnea, claudication, exercise intolerance, or history of heart attack. Patient does report swelling of the lower extremities and hypertension. Patient cannot recall last EKG or if ever has had a stress test.
Breasts: denies any breast changes, discharge, redness, or tenderness. Patient does report has a lipoma above the left breast. Patient states does go routinely for mammograms, and the last several have been normal. She denies performing home breast self-exams.
Genitourinary: denies any flank pain, hematuria, nocturia, hesitancy, passing of a stone, facial swelling, or history of sexually transmitted infections. Patient does report dysuria, suprapubic pain, urgency, frequency, and odorous urine.
Abdomen: denies any nausea, vomiting, difficulty swallowing, incontinence, diarrhea, intolerance to foods, stool changes, flatulence, or appetite changes. Patient denies any history of hepatitis, diverticulitis, or ulcers. Patient does report a history of hemorrhoids, reflux, and normal colonoscopy within the past ten years.
Peripheral vascular: denies any claudication, tendencies to bruise or bleed easily, or blood clots.
Musculoskeletal: denies any joint redness, limits to range of motion, or warm joints. Patient does report has osteoarthritis of the hands, some joint swelling of the fingers, and morning hand stiffness.
Neurological: denies any syncope, seizures, weakness, paralysis, tremors, or coordination difficulties. Patient does report have occasional tingling and burning neuropathy of the left lower leg and foot.
Mental Status: denies any depression, anxiety, mood changes, nervousness, problems with concentration, or feelings of irritability. Patient does report a history of insomnia, which is well controlled with Temazepam.
OBJECTIVE DATA:
Physical exam:
General Appearance: Patient is a well-developed, 81 year old Caucasian female, appearing of stated age.
Vital Signs: HT: 5’5”, WT: 176lbs, BP: 110/80, HR: 64, RR: 18, T: 98.4, pain: “0/10,” BMI: 29.2
Integument: Skin is warm and dry to touch. Normal skin turgor. No noted rashes, bites, open wounds, or lesions. Patient has normally distributed, shaped, and colored nevi. Hair is evenly distributed over scalp. Noted white fungal area to half of right great toenail. Superficial lipomas x3, one to the upper left breast area, one to the left upper abdomen, and one to the right forearm, each about 1” x1” in size. Noted three seborrheic keratosis lesions on face.
Head, Ears, Eyes, Nose, Mouth, and Neck: Head is normocephalic with normal distribution of hair. No noted facial swelling. Conjunctiva are pink with white sclera and without jaundice. PERRLA, with pupils 3mm in size bilaterally. No hemorrhaging or exudates seen. Tympanic membranes intact without erythema, external auditory canals with mild amounts of cerumen and without erythema. Hearing is grossly intact. Nasopharynx and pharynx without erythema, lesions, or exudates. Mucous membranes moist. Upper and lower dentures intact and in good condition. Trachea is midline with slightly palpable thyroid, which rises upon swallowing.
Lymphatic: No lymphadenopathy.
Chest/Respiratory: Lungs are clear to auscultation anteriorly and posteriorly with equal symmetry of chest rise and fall. Resonance noted to posterior percussion bilaterally. No cough, wheezes, rhonchi, use of accessory muscles, or stridor.
Cardiac: Irregular heart rate at 64 beats per minute. PMI: 5th intercostal space, midclavicular line. S1 and S2 normal without murmurs, gallops, or splits. No abdominal, carotid, or femoral bruits. No JVD.
Breasts: No lymphadenopathy, nipple retraction, or nipple discharge. Palpated 1”x1” superficial lipoma above left breast.
Genitourinary: No inguinal hernias, suprapubic pain with palpation, no CVA tenderness. External genitalia with mild hair distribution, no masses, lesions, or swelling. Urethral meatus intact with no discharge or erythema. Perineum intact and without lesions. Vaginal mucosa pink, minimal rugae, no foul odor, no discharge, cervix absent with scar tissue intact. Bimanual exam without masses. Rectovaginal exam: septum intact, sphincter tone intact, no masses or tenderness.
Abdomen: Abdomen soft, nontender, nondistended, with normal bowel sounds present. Tympany noted to percussion. No hernias, hepatomegaly, spleenomegally, or masses. No CVA tenderness or abdominal bruits.
Peripheral vascular: Bilateral non-pitting lower extremity edema. Negative Homan’s sign. 2+ palpable radial and dorsalis pedis pulses. Mild scattered varicosities to lower extremities. Capillary refill less than 3 seconds. No cyanosis or clubbing present.
Musculoskeletal: Range of motion exercises within normal limits without pain or crepitus, 4+ muscle strength bilaterally, mild swelling of the DIP and PIP joints bilaterally, mildly tender to touch, no joint erythema. Other joints without erythema, without swelling or tenderness. Slight kyphosis noted.
Neurological: Cranial nerves II-XII intact. Noted slight nystagmus with EOM exam. Hearing grossly intact. Negative Rhomberg exam, 2+ deep tendon reflexes of the brachial, triceps, brachioradial, patellar, and achilles tendons. No tremors noted. No slurred speech. Patient is alert and oriented times three. Rapid altering movements intact.
Mental Status: Patient alert and oriented times 3. Able to follow commands. Memory intact. Appropriate responses with conversation. Patient with normal affect. Does not appear anxious or tearful. Smiles with conversation.
DATE OF SERVICE: September 20, 2013
Chief Complaint: “bladder pain,” and annual wellness exam.
History of Present Illness: Patient presents today with the complaints of bladder pain and for her annual wellness visit. The patient states the pain comes and goes, sometimes feeling like a burning sensation and other times as a sharp pain. The patient has a history of receiving bladder surgery with a sling, “years,” ago which she states has been having recurrent UTI’s and bladder pain ever since the surgery. The patient states the bladder surgery was by her current OBGYN. She states she does feel as though she empties her bladder completely with each urination. She does report a foul odor to her urine, frequency, and urinary stress incontinence. She denies any fever, chills, sweats, nausea, vomiting, vaginal itching or discharge, hematuria, or changes to her urine color. The patient states she drinks large amounts of water and green tea. Patient states cannot recall any particular aggravating or alleviating factors to the pain other than the actual pain with urination.
Past Medical History:
1. Cervical cancer
2. Total hysterectomy
3. Left ventricular hypertrophy
4. Hypertension
5. Hemorrhoids
6. Osteoarthritis
7. Edema
8. Tinnitus
9. Onychomycosis
10. Bladder surgery with sling
11. Insomnia
12. Gastroesophageal reflux disease
13. Hypothyroidism
Family History:
1. Father deceased at age 92 with cardiac disease
2. Mother deceased in her 60’s of cancer
3. One brother deceased at age 84 with cardiac disease
4. Second brother deceased at age 60 with cardiac disease
5. One sister deceased in her 50’s with cardiac disease
6. Two other sisters deceased with strokes
7. One son with diabetes and hypertension
8. Two other children healthy and living
Social History:
1. Tobacco use, quit smoking 43 years ago
2. Denies alcohol use
3. Moderate caffeine intake. Patient states drinks moderate amounts of green tea
4. Exercises several times a week at home
5. Married
6. Denies multiple sex partners
7. Denies illegal drug use
Allergies: Patient has no drug, environmental, or food allergies
Current Medications:
1. Synthroid, 100 mcg P.O daily
2. Lasix 20 mg P.O. daily
3. Multivitamin one P.O. daily
4. Vitamin D OTC, one P.O. prn
5. Temazepam 15 mg P.O. daily
6. Omeprazole 40 mg P.O. prn
Immunization Status:
1. Influenza vaccine: 2012
2. Pneumonia vaccine: Up to date
3. Tetanus vaccine: Up to date
4. Patient unable to report immunization history other than listed above
Review of Systems:
General: denies any fever, chills, malaise, night sweats, or any recent weight loss or gain.
Head, Ears, Eyes, Nose, Mouth, and Neck: denies any headaches, dizziness, visual loss, blurred vision, double vision, history of concussions, nose bleeds, ear infections, light sensitivity, history of glaucoma or cataracts, difficulty swallowing, throat swelling, or any throat, ear, or nasal pain. Patient does wear reading glasses, wears upper and lower dentures, and states she routinely sees an ophthalmologist. She also reports a history of tinnitus.
Lymphatic: denies any enlarged, reddened, or tender lymph nodes.
Integumentary: denies any rashes, changes to moles, easy bruising, itching, excessive sweating, or bites. Patient does report dry skin, having several fatty lipomas, and fungal infection to right great toe.
Chest/ Respiratory: denies any cough, wheezing, shortness of breath, sputum, sleep apnea, painful breathing, hemoptysis, night sweats, or exposure to tuberculosis. Patient does not recall ever having a TB skin test.
Cardiac: denies any chest pain, palpitations, dyspnea, orthopnea, claudication, exercise intolerance, or history of heart attack. Patient does report swelling of the lower extremities and hypertension. Patient cannot recall last EKG or if ever has had a stress test.
Breasts: denies any breast changes, discharge, redness, or tenderness. Patient does report has a lipoma above the left breast. Patient states does go routinely for mammograms, and the last several have been normal. She denies performing home breast self-exams.
Genitourinary: denies any flank pain, hematuria, nocturia, hesitancy, passing of a stone, facial swelling, or history of sexually transmitted infections. Patient does report dysuria, suprapubic pain, urgency, frequency, and odorous urine.
Abdomen: denies any nausea, vomiting, difficulty swallowing, incontinence, diarrhea, intolerance to foods, stool changes, flatulence, or appetite changes. Patient denies any history of hepatitis, diverticulitis, or ulcers. Patient does report a history of hemorrhoids, reflux, and normal colonoscopy within the past ten years.
Peripheral vascular: denies any claudication, tendencies to bruise or bleed easily, or blood clots.
Musculoskeletal: denies any joint redness, limits to range of motion, or warm joints. Patient does report has osteoarthritis of the hands, some joint swelling of the fingers, and morning hand stiffness.
Neurological: denies any syncope, seizures, weakness, paralysis, tremors, or coordination difficulties. Patient does report have occasional tingling and burning neuropathy of the left lower leg and foot.
Mental Status: denies any depression, anxiety, mood changes, nervousness, problems with concentration, or feelings of irritability. Patient does report a history of insomnia, which is well controlled with Temazepam.
OBJECTIVE DATA:
Physical exam:
General Appearance: Patient is a well-developed, 81 year old Caucasian female, appearing of stated age.
Vital Signs: HT: 5’5”, WT: 176lbs, BP: 110/80, HR: 64, RR: 18, T: 98.4, pain: “0/10,” BMI: 29.2
Integument: Skin is warm and dry to touch. Normal skin turgor. No noted rashes, bites, open wounds, or lesions. Patient has normally distributed, shaped, and colored nevi. Hair is evenly distributed over scalp. Noted white fungal area to half of right great toenail. Superficial lipomas x3, one to the upper left breast area, one to the left upper abdomen, and one to the right forearm, each about 1” x1” in size. Noted three seborrheic keratosis lesions on face.
Head, Ears, Eyes, Nose, Mouth, and Neck: Head is normocephalic with normal distribution of hair. No noted facial swelling. Conjunctiva are pink with white sclera and without jaundice. PERRLA, with pupils 3mm in size bilaterally. No hemorrhaging or exudates seen. Tympanic membranes intact without erythema, external auditory canals with mild amounts of cerumen and without erythema. Hearing is grossly intact. Nasopharynx and pharynx without erythema, lesions, or exudates. Mucous membranes moist. Upper and lower dentures intact and in good condition. Trachea is midline with slightly palpable thyroid, which rises upon swallowing.
Lymphatic: No lymphadenopathy.
Chest/Respiratory: Lungs are clear to auscultation anteriorly and posteriorly with equal symmetry of chest rise and fall. Resonance noted to posterior percussion bilaterally. No cough, wheezes, rhonchi, use of accessory muscles, or stridor.
Cardiac: Irregular heart rate at 64 beats per minute. PMI: 5th intercostal space, midclavicular line. S1 and S2 normal without murmurs, gallops, or splits. No abdominal, carotid, or femoral bruits. No JVD.
Breasts: No lymphadenopathy, nipple retraction, or nipple discharge. Palpated 1”x1” superficial lipoma above left breast.
Genitourinary: No inguinal hernias, suprapubic pain with palpation, no CVA tenderness. External genitalia with mild hair distribution, no masses, lesions, or swelling. Urethral meatus intact with no discharge or erythema. Perineum intact and without lesions. Vaginal mucosa pink, minimal rugae, no foul odor, no discharge, cervix absent with scar tissue intact. Bimanual exam without masses. Rectovaginal exam: septum intact, sphincter tone intact, no masses or tenderness.
Abdomen: Abdomen soft, nontender, nondistended, with normal bowel sounds present. Tympany noted to percussion. No hernias, hepatomegaly, spleenomegally, or masses. No CVA tenderness or abdominal bruits.
Peripheral vascular: Bilateral non-pitting lower extremity edema. Negative Homan’s sign. 2+ palpable radial and dorsalis pedis pulses. Mild scattered varicosities to lower extremities. Capillary refill less than 3 seconds. No cyanosis or clubbing present.
Musculoskeletal: Range of motion exercises within normal limits without pain or crepitus, 4+ muscle strength bilaterally, mild swelling of the DIP and PIP joints bilaterally, mildly tender to touch, no joint erythema. Other joints without erythema, without swelling or tenderness. Slight kyphosis noted.
Neurological: Cranial nerves II-XII intact. Noted slight nystagmus with EOM exam. Hearing grossly intact. Negative Rhomberg exam, 2+ deep tendon reflexes of the brachial, triceps, brachioradial, patellar, and achilles tendons. No tremors noted. No slurred speech. Patient is alert and oriented times three. Rapid altering movements intact.
Mental Status: Patient alert and oriented times 3. Able to follow commands. Memory intact. Appropriate responses with conversation. Patient with normal affect. Does not appear anxious or tearful. Smiles with conversation.