Patient initials and age: JT, 29
DATE OF SERVICE: November 11, 2013
CHIEFT COMPLAINT: “Leg pain”
HISTORY OF PRESENT ILLNESS: This is a 29-year-old, Caucasian male, with a history of degenerative disc disease. Patient states he is visiting today, to establish a primary care provider before leaving on a temporary job in Texas. Patient states he is a former college baseball player with many sport related injuries in the past. Over the past year, lower back pain and right lower extremity pain has increased. Patient states the right lower extremity pain is intermittently sharp, with occasional burning and loss of sensation, and sometimes his right leg will, “give out.” He describes the location of the pain being on the lateral area of the right thigh, radiating down to the knee. He also states right hip occasionally dislocates in which he is able to put back in place himself. Patient reports no obvious triggers to initiate the symptoms but does find some relief by taking prescribed Oxycontin and rest.
ALLERGIES: No known drug, environmental, or food allergies
MEDICATIONS:
IMMUNIZATION STATUS:
Tetanus: 2011
Influenza: Patient denies ever receiving
Pneumococcal: Patient denies ever receiving
Patient is unsure or previous vaccination status other than his tetanus vaccine last year. He declines the influenza or pneumococcal vaccine this visit
PAST MEDICAL HISTORY:
PAST SURGICAL HISTORY:
1. Right inguinal hernia surgery 2006
2. Right ulnar collateral ligament reconstruction 2009
3. Parotidectomy 2005
4. Melanoma removal x’s 3
SOCIAL HISTORY:
1. Smokes ½ packs per day x’s 14 years
2. Occasional alcohol usage
3. Moderate caffeine usage
4. Denies recreational drug use
5. Currently married, but separated from wife at this time
6. Patient states is sexually active, with new girlfriend only
7. Highest level of education: Associates Degree
8. Pt. does not have health insurance, seeking care to establish primary care practitioner before leaving to Texas for a temporary job on an oil rig
9. Pt. states he does not exercise anymore. He is a former college baseball player
FAMILY HISTORY:
1. Father currently living at age 62 with hypertension
2. Mother deceased at age 40 with melanoma
3. Uncle deceased at age 50 with an acute myocardial infarction
4. Grandparents currently living
5. Does not have any siblings
6. Daughter living, 5 years old
REVIEW OF SYSTEMS:
General: Patient denies any fever, chills, malaise, night sweats, or changes in weight. Patient states current height is 6’0.5”
Integument: Denies any rashes, insect bites, recent burns, excessive sweating, itching, swelling, bruising, or recent changes to freckles or moles. Patient does see a dermatologist routinely due to previous melanomas.
Head, Ears, Eyes, Nose, Mouth, and Neck: Reports sinus headaches and congestion intermittently, occasional blurry vision, and intermittent neck pain on right side near area of previous surgery. Patient denies any loss of vision, double vision, sensitivity to light, dizziness, syncope, brain injuries, hearing loss, ear pain, ear, nasal, or eye discharge, vertigo, tinnitus, changes in voice, hoarseness, loss of teeth, dry mouth, changes in smell or taste. Patient does not wear glasses or contacts.
Lymphatic: Patient denies any noticed enlarge lymph nodes or painful nodes
Chest and lungs: Patient reports having obstructive sleep apnea and sleeps on 3 pillows at night. Denies any shortness of breath, pain with breathing, coughing, sputum, wheezing, night sweats. Patient denies ever having PPD test.
Cardiac: Patient states he does have hypertension. He states it is related to stress and anxiety. Patient reports occasional, sharp, shooting, chest pain over past three weeks, lasting less than 45 seconds each episode, 9/10 on a 1-10 pain scale, with the pain in left upper anterior chest area radiating down to arm. Patient states at same time experiences intermittent palpitations. He associates the pain with times of anxiety, occurring more at night. He denies any precipitating or alleviating factors for the pain. Patient denies dyspnea, edema, claudication, history of heart attack, difficulty walking or working, or ever having EKG, echocardiogram, or stress test.
Breasts: Patient denies any breast pain, tenderness, lumps, or discharge.
Genitourinary: Patient reports a noticed darker color in urine over past week, with dysuria, bladder pain, and frequency. Patient denies any hematuria, dribbling, change in stream, incontinence, or nocturia. Patient states he drinks a large amount of sodas and tea.
Gastrointestinal: Patient reports frequent heartburn, which he states is unrelieved by the current use of Prilosec and Sucralfate. Patient reports history of stomach ulcers. Patient denies any weight loss or gain, changes in appetite, dysphagia, nausea, vomiting, diarrhea, hematemesis, constipation, hemorrhoids, history of liver disease, gallstones, or changes in stool appearance. Patient states he has never had EGD or colonoscopy.
Peripheral vascular: Patient denies any claudication, tendencies to bruise easily, blood clots, or numbness of extremities.
Musculoskeletal: Patient is a former baseball player with several sports related injuries. Patient reports pain, stiffness, and difficulty moving lower back, right hip, right knee, and right shoulder, and a previous job of lifting tombstones for grave yards. He states this created the back pain he now experiences. Patient reports a lower back compressed disc and sciatic pain. Patient states he has intermittent pain when ambulating that shoots down the right, lateral thigh, down to the knee, and then the leg becomes numb. He also reports his right hip intermittently will dislocate, and he is able to put back in place himself. Patient states all complaints stem from various forms of activity and are relieved somewhat with his prescribed Oxycontin. Patient denies any swelling, redness or heat at any of the joint sites.
Neurological: Patient reports tingling and sharp shooting pains to the right cheek area of the face, with noted increased pain and sensitivity to light touch in this area. Patient states he has had this symptom since his parotidectomy. Patient also reports intermittent numbness and sharp shooting pains down the right leg. Patient denies any tremors, syncope, or seizures.
Psychiatric: Patient reports increased anxiety with recent separation from his wife and job relocation. Patient denies any depression, suicidal ideations, difficulty concentrating, irritability, or sleep disturbances.
Hematologic: Patient denies any blood disorders, anemia, or previous blood transfusions.
Endocrine: Patient does report increased anxiety. Patient denies any difficulty
swallowing, changes to his neck, intolerance to heat or cold, weight loss or gain, or changes to skin.
PHYSICAL EXAMINATION:
General Appearance: Patient presents as a well-developed, young adult Caucasian who appears his stated age. He is alert, oriented, and cooperative.
Vital signs: Blood pressure: 150/90; heart rate: 130; respirations: 18; temperature: 99.3̊ F; pain: 0/10 on 1-10 scale at rest. Weight is 217 lbs.
Integumentary: skin warm and dry to touch. No noted rashes, open wounds, or lesions. Patient has normally distributed, shaped, and colored nevi. Hair is evenly distributed over scalp.
Head, Ears, Eyes, Nose, Mouth, and Neck: head is normocephalic with normal distribution of hair. Noted facial tenderness to right cheek area to light sensation. Conjunctiva are pink with white sclera and without jaundice. PERLA, with pupils 3mm in size bilaterally. No hemorrhaging or exudates seen. Tympanic membranes intact without erythema, external auditory canals with moderate amounts of cerumen and without erythema. Hearing is grossly intact. Nasopharynx and pharynx without erythema, lesions, or exudates. Mucous membranes moist. Upper and lower teeth in good condition and intact. Trachea is midline with slightly palpable thyroid. No JVD present. No cervical, supraclavicular, or axillary lymph nodes palpable.
Chest: Lungs clear to auscultation anteriorly and posteriorly with equal symmetry of chest rise and fall. Resonance noted to percussion bilaterally. No wheezes, rhonchi or stridor.
Cardiac: Regular rate and rhythm. PMI: 5th intercostal space, midclavicular line. S1 and s2 normal with no murmurs or splits. No abdominal, carotid, or femoral bruits. No JVD.
Breasts: No lymphadenopathy, masses, nipple retraction, or nipple discharge
Genitourinary: No inguinal hernias, penis and testicles without lesions. Pain noted on palpitation of bladder. No CVA tenderness.
Abdomen: soft, nontender, nondistended. With normal bowel sounds x’s 4 quadrants. No palpable masses. No hepatomegaly, splenomegaly.
Peripheral vascular: No edema of extremities. 2+ palpable radial, posterior tibial, and dorsalis pedis pulses. Normal distribution of hair on lower extremities. Normal color. Capillary refill less than 3 seconds. No cyanosis or clubbing present.
Musculoskeletal: No erythema or deformities of joints. Limited ROM of right shoulder with pain. Pain to lower back with adduction and lowering of left leg when lying flat. Noted lower back pain with abduction and lowering of right leg when lying flat. Pain to right trochanter with palpation. Minimal flexion of right knee due to pain. No crepitus to palpitation of joints. Other joints unremarkable.
Neurological: Cranial nerves II-IV intact and cranial nerves VI-XII intact. Noted pain to light touch to right cheek; patient unable to differentiate sharp and dull, only pain at site. Hearing grossly intact. DTRs 2+ bilaterally. Normal gait with ambulation.
Mental Status: Patient is alert, oriented x’s 3, with fluent, no slurred speech, appropriate mood and affect. Able to follow commands. No disordered thought process apparent.
DATE OF SERVICE: November 11, 2013
CHIEFT COMPLAINT: “Leg pain”
HISTORY OF PRESENT ILLNESS: This is a 29-year-old, Caucasian male, with a history of degenerative disc disease. Patient states he is visiting today, to establish a primary care provider before leaving on a temporary job in Texas. Patient states he is a former college baseball player with many sport related injuries in the past. Over the past year, lower back pain and right lower extremity pain has increased. Patient states the right lower extremity pain is intermittently sharp, with occasional burning and loss of sensation, and sometimes his right leg will, “give out.” He describes the location of the pain being on the lateral area of the right thigh, radiating down to the knee. He also states right hip occasionally dislocates in which he is able to put back in place himself. Patient reports no obvious triggers to initiate the symptoms but does find some relief by taking prescribed Oxycontin and rest.
ALLERGIES: No known drug, environmental, or food allergies
MEDICATIONS:
- Xanax 1 mg P.O. T.I.D
- Oxycontin IR 30 mg P.O. four times daily
- Synthroid 0.125mg P.O. daily
- Flexeril 10mg PO QHS
- Sucralfate 1mg P.O. T.I.D.
- Neurontin 100mg P.O. daily
- Lisinopril 20 mg daily
- Prilosec 20 mg P.O. daily
IMMUNIZATION STATUS:
Tetanus: 2011
Influenza: Patient denies ever receiving
Pneumococcal: Patient denies ever receiving
Patient is unsure or previous vaccination status other than his tetanus vaccine last year. He declines the influenza or pneumococcal vaccine this visit
PAST MEDICAL HISTORY:
- Malignant melanoma removal x’s 3
- Anxiety
- Gastrointestinal ulcers
- Gastroesophageal reflux disease
- Degenerative disc disease
- Parotid gland malignancy with parotidectomy
- Obstructive sleep apnea
- Rotator cuff injury
- Elbow sports injury with ulnar collateral ligament reconstruction
PAST SURGICAL HISTORY:
1. Right inguinal hernia surgery 2006
2. Right ulnar collateral ligament reconstruction 2009
3. Parotidectomy 2005
4. Melanoma removal x’s 3
SOCIAL HISTORY:
1. Smokes ½ packs per day x’s 14 years
2. Occasional alcohol usage
3. Moderate caffeine usage
4. Denies recreational drug use
5. Currently married, but separated from wife at this time
6. Patient states is sexually active, with new girlfriend only
7. Highest level of education: Associates Degree
8. Pt. does not have health insurance, seeking care to establish primary care practitioner before leaving to Texas for a temporary job on an oil rig
9. Pt. states he does not exercise anymore. He is a former college baseball player
FAMILY HISTORY:
1. Father currently living at age 62 with hypertension
2. Mother deceased at age 40 with melanoma
3. Uncle deceased at age 50 with an acute myocardial infarction
4. Grandparents currently living
5. Does not have any siblings
6. Daughter living, 5 years old
REVIEW OF SYSTEMS:
General: Patient denies any fever, chills, malaise, night sweats, or changes in weight. Patient states current height is 6’0.5”
Integument: Denies any rashes, insect bites, recent burns, excessive sweating, itching, swelling, bruising, or recent changes to freckles or moles. Patient does see a dermatologist routinely due to previous melanomas.
Head, Ears, Eyes, Nose, Mouth, and Neck: Reports sinus headaches and congestion intermittently, occasional blurry vision, and intermittent neck pain on right side near area of previous surgery. Patient denies any loss of vision, double vision, sensitivity to light, dizziness, syncope, brain injuries, hearing loss, ear pain, ear, nasal, or eye discharge, vertigo, tinnitus, changes in voice, hoarseness, loss of teeth, dry mouth, changes in smell or taste. Patient does not wear glasses or contacts.
Lymphatic: Patient denies any noticed enlarge lymph nodes or painful nodes
Chest and lungs: Patient reports having obstructive sleep apnea and sleeps on 3 pillows at night. Denies any shortness of breath, pain with breathing, coughing, sputum, wheezing, night sweats. Patient denies ever having PPD test.
Cardiac: Patient states he does have hypertension. He states it is related to stress and anxiety. Patient reports occasional, sharp, shooting, chest pain over past three weeks, lasting less than 45 seconds each episode, 9/10 on a 1-10 pain scale, with the pain in left upper anterior chest area radiating down to arm. Patient states at same time experiences intermittent palpitations. He associates the pain with times of anxiety, occurring more at night. He denies any precipitating or alleviating factors for the pain. Patient denies dyspnea, edema, claudication, history of heart attack, difficulty walking or working, or ever having EKG, echocardiogram, or stress test.
Breasts: Patient denies any breast pain, tenderness, lumps, or discharge.
Genitourinary: Patient reports a noticed darker color in urine over past week, with dysuria, bladder pain, and frequency. Patient denies any hematuria, dribbling, change in stream, incontinence, or nocturia. Patient states he drinks a large amount of sodas and tea.
Gastrointestinal: Patient reports frequent heartburn, which he states is unrelieved by the current use of Prilosec and Sucralfate. Patient reports history of stomach ulcers. Patient denies any weight loss or gain, changes in appetite, dysphagia, nausea, vomiting, diarrhea, hematemesis, constipation, hemorrhoids, history of liver disease, gallstones, or changes in stool appearance. Patient states he has never had EGD or colonoscopy.
Peripheral vascular: Patient denies any claudication, tendencies to bruise easily, blood clots, or numbness of extremities.
Musculoskeletal: Patient is a former baseball player with several sports related injuries. Patient reports pain, stiffness, and difficulty moving lower back, right hip, right knee, and right shoulder, and a previous job of lifting tombstones for grave yards. He states this created the back pain he now experiences. Patient reports a lower back compressed disc and sciatic pain. Patient states he has intermittent pain when ambulating that shoots down the right, lateral thigh, down to the knee, and then the leg becomes numb. He also reports his right hip intermittently will dislocate, and he is able to put back in place himself. Patient states all complaints stem from various forms of activity and are relieved somewhat with his prescribed Oxycontin. Patient denies any swelling, redness or heat at any of the joint sites.
Neurological: Patient reports tingling and sharp shooting pains to the right cheek area of the face, with noted increased pain and sensitivity to light touch in this area. Patient states he has had this symptom since his parotidectomy. Patient also reports intermittent numbness and sharp shooting pains down the right leg. Patient denies any tremors, syncope, or seizures.
Psychiatric: Patient reports increased anxiety with recent separation from his wife and job relocation. Patient denies any depression, suicidal ideations, difficulty concentrating, irritability, or sleep disturbances.
Hematologic: Patient denies any blood disorders, anemia, or previous blood transfusions.
Endocrine: Patient does report increased anxiety. Patient denies any difficulty
swallowing, changes to his neck, intolerance to heat or cold, weight loss or gain, or changes to skin.
PHYSICAL EXAMINATION:
General Appearance: Patient presents as a well-developed, young adult Caucasian who appears his stated age. He is alert, oriented, and cooperative.
Vital signs: Blood pressure: 150/90; heart rate: 130; respirations: 18; temperature: 99.3̊ F; pain: 0/10 on 1-10 scale at rest. Weight is 217 lbs.
Integumentary: skin warm and dry to touch. No noted rashes, open wounds, or lesions. Patient has normally distributed, shaped, and colored nevi. Hair is evenly distributed over scalp.
Head, Ears, Eyes, Nose, Mouth, and Neck: head is normocephalic with normal distribution of hair. Noted facial tenderness to right cheek area to light sensation. Conjunctiva are pink with white sclera and without jaundice. PERLA, with pupils 3mm in size bilaterally. No hemorrhaging or exudates seen. Tympanic membranes intact without erythema, external auditory canals with moderate amounts of cerumen and without erythema. Hearing is grossly intact. Nasopharynx and pharynx without erythema, lesions, or exudates. Mucous membranes moist. Upper and lower teeth in good condition and intact. Trachea is midline with slightly palpable thyroid. No JVD present. No cervical, supraclavicular, or axillary lymph nodes palpable.
Chest: Lungs clear to auscultation anteriorly and posteriorly with equal symmetry of chest rise and fall. Resonance noted to percussion bilaterally. No wheezes, rhonchi or stridor.
Cardiac: Regular rate and rhythm. PMI: 5th intercostal space, midclavicular line. S1 and s2 normal with no murmurs or splits. No abdominal, carotid, or femoral bruits. No JVD.
Breasts: No lymphadenopathy, masses, nipple retraction, or nipple discharge
Genitourinary: No inguinal hernias, penis and testicles without lesions. Pain noted on palpitation of bladder. No CVA tenderness.
Abdomen: soft, nontender, nondistended. With normal bowel sounds x’s 4 quadrants. No palpable masses. No hepatomegaly, splenomegaly.
Peripheral vascular: No edema of extremities. 2+ palpable radial, posterior tibial, and dorsalis pedis pulses. Normal distribution of hair on lower extremities. Normal color. Capillary refill less than 3 seconds. No cyanosis or clubbing present.
Musculoskeletal: No erythema or deformities of joints. Limited ROM of right shoulder with pain. Pain to lower back with adduction and lowering of left leg when lying flat. Noted lower back pain with abduction and lowering of right leg when lying flat. Pain to right trochanter with palpation. Minimal flexion of right knee due to pain. No crepitus to palpitation of joints. Other joints unremarkable.
Neurological: Cranial nerves II-IV intact and cranial nerves VI-XII intact. Noted pain to light touch to right cheek; patient unable to differentiate sharp and dull, only pain at site. Hearing grossly intact. DTRs 2+ bilaterally. Normal gait with ambulation.
Mental Status: Patient is alert, oriented x’s 3, with fluent, no slurred speech, appropriate mood and affect. Able to follow commands. No disordered thought process apparent.