H&P1

HISTORY:

Identifying data:

Date & Time: August 29, 2023, 9:30am

Full name: Ms.D.K

Address: Flushing, NY

Date of birth: February 2, 1995

Location: NYPQ, Flushing, NY

Religion: Atheist

Marital status: Single

Source of information: Self

Reliability: Reliable

Source of referral: Neuro

Mode of transport: Mom

Chief Complaint:

“Scheduled appointment for an EEG ”

History of Present Illness: 

28 y/o with PMH of focal dysplasia, epilepsy was admitted to the IM for an EEG after epileptic episode Sunday afternoon.Pt states a recent seizure on Sunday while using the restroom lasting approximately 3 minutes. Pt recently switched to Aptiom 400 mg 4x daily and Clobazam 10mg twice daily. Pt was previously on Carbamazepine with no positive therapeutic effect. Pt recent seizure was not due to missed dose as she states she is adherent to the regimen. Pt neurologist, Dr.Shaw is currently monitoring Ms. D.K EEG to determine different surgery options.  Denies any sensory disturbances, visual disturbances or motor impairment.

Past Medical History: 

  • Epilepsy x 20 years, well controlled on medications
  • Immunizations: up to date; flu vaccine yearly (unknown date); Covid vaccines and booster up to date (unknown dates).
  • Past Hospitalization: December 2020, medication change due to worsening seizures.

Past Surgical History:

  • Denies any past Surgical History 

Medications:

  • Aptiom 400 mg, 1 tab PO 4x daily, for epilepsy 
  • Clobazam 10 mg, 1 tab PO twice daily
  • Denies use of herbal supplements.

Allergies:

  • NKDA, no food or environmental allergies.

Family History: 

  • Mother – 65 alive, hx of diabetes.
  • Father – 70 alive and well.
  • Brother – Age 30, alive and well.

Social History:

  • Habits – Admits to caffeine use, 1 cup of coffee in morning. Nonsmoker, denies alcohol use.
  • Travel – No recent travel.
  • Marital history – Single.
  • Occupational history – Starting new job at Senior Care
  • Home situation – Lives with Mother. 
  • Diet – Admits to a balanced diet consisting of protein, grains, vegetables.
  • Sleep patterns – Admits to good sleep pattern.
  • Exercise – Pt admits to walking around her neighborhood once daily. Denies any form of strenuous activities at this time.
  • Safety Measures: Admits to wearing seatbelts.
  • Sexual History: Heterosexual. Not sexually active. 

Review of Systems:

  • General: Denies generalized weakness/fatigue, fever, chills, night sweats, weight loss of gain, changes in appetite.
  • Skin, hair, nails: Denies changes in texture, excessive dryness or sweating, discolorations, pigmentations, moles/rashes, pruritus, changes in hair distribution.
  • Head: Denies headaches, vertigo, head trauma.
  • Eyes: Last eye exam 5 months ago. Prescription glasses for nearsightedness  OD: -3.5  OU: -3.25 Denies any  lacrimation, pruritus, visual disturbances, photophobia.
  • Ears: Denies deafness, pain, discharge, tinnitus, hearing aid use.
  • Nose: Denies discharge, obstruction, epistaxis.
  • Mouth/throat: Last dental exam about 2 months ago. Denies voice changes, bleeding gums, sore tongue, sore throat, mouth ulcers, dentures use.
  • Neck: Denies localized swelling/lumps, stiffness/decreased ROM
  • Breast: Denies lumps, nipple discharge, pain.
  • Pulmonary: Denies dyspnea, dyspnea on exertion, orthopnea, paroxysmal nocturnal dyspnea, cough, wheezing, cyanosis, hemoptysis..
  • Cardiovascular: Denies chest pain, palpitations, hx of HTN, irregular heartbeat, edema/swelling of ankles or feet, syncope, known heart murmur.
  • Gastrointestinal: Denies loss of appetite, intolerance to specific foods, nausea and vomiting, dysphagia, pyrosis, flatulence, eructation, abdominal pain, diarrhea, jaundice, change in bowel habits, hemorrhoids, constipation, rectal bleeding, or blood in stool. 
  • Genitourinary:  Denies urinary frequency, nocturia, urgency, oliguria, polyuria, dysuria, incontinence, awakening at night to 
  • Sexual History: Denies impotence, history of STIs, contraception use, abnormal discharge.
  • Musculoskeletal: Denies arthritis, muscle pain, deformity or swelling, redness.
  • Nervous system: History of seizures for past 20 years.Pt episodes include loss of consciousness along with occasional headaches. Reports after episodes feeling of loss of strength and gradual decrease in memory retention. Denies Sensory disturbances 
  • Peripheral vascular: Denies intermittent claudication, varicose veins, coldness or trophic changes, peripheral edema or color changes.
  • Hematologic: Denies anemia, easy bruising or bleeding, lymph node enlargement, blood transfusions, history of DVT/PE.
  • Endocrine: Denies polyuria, polydipsia, polyphagia, heat or cold intolerance, excessive sweating, goiter, hirsutism.
  • Psychiatric:  Denies depression/sadness, anxiety, OCD, or ever seeing a mental health professional.

PHYSICAL: 

General: Slender female, neatly groomed, appears her stated age of 28. Pt is currently sitting on a hospital chair , A&O x4, and in no acute distress.

Vital Signs:

BP:              R                             L

Seated         120/82                     121/86

Supine         116/80                     122/84

R: 16/min, unlabored                      P: 64 beats/min, regular

T: 98.8 degrees F (oral)                  O2 Sat: 99% Room air

Height: 66   Weight: 125 lbs      BMI: 20.2

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

Hair: Short, black hair, average quantity and distribution.

Nails: No clubbing, capillary refill < 2 seconds in upper and lower extremities.

Head: Normocephalic, atraumatic, non-tender to palpation throughout.

Ears: Symmetrical and appropriate in size. No lesions, masses or trauma on external ears. No discharge or foreign bodies on external auditory canals AU. TM pearly grey and intact with light reflect in good position AU. Auditory acuity intact to whispered voice AU. Weber midline. Rinne reveals AC > BC AU.

Nose: Symmetrical. No masses, lesions, deformities, trauma or discharge. Nares patent bilaterally, nasal mucosa pink & well hydrated. No discharge noted on anterior rhinoscopy. Septum midline without lesions, deformities, injection or perforation. No foreign bodies.

Sinuses: Non tender to palpation and percussion over bilateral frontal, ethmoid and maxillary sinuses.

Mouth/Pharynx-

Lips: Pink, moist, no cyanosis or lesions.

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

Palate: Pink, well hydrated. Palate intact with no lesions, masses, scars.

Teeth: Good dentition, no obvious dental caries noted.

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

Tongue: Pink, well hydrated. No masses, lesions or deviation.

Oropharynx: Well hydrated. No injection, exudates, masses, lesions or foreign bodies. Tonsils grade 2 present with no injection or exudate. Uvula pink, no edema or lesions.

Neck: Trachea midline. No masses, lesions, scars, or pulsations noted. Supple; non-tender to

palpation. FROM; no stridor noted. 2+ Carotid pulses, no thrills; bruits noted bilaterally, no cervical adenopathy noted.

Thyroid: Non-tender; no palpable masses; no thyromegaly; no bruits noted.

or lacerations, and nontender to palpation throughout.

Eyes: Symmetrical OU. No strabismus, exophthalmos, or ptosis. Sclera white, cornea clear, conjunctiva pink.
Visual acuity – corrected, 20/20 OS, 20/20 OD, 20/20 OU (done on friend).
Visual fields – full OU. PERRLA. EOMs intact with no nystagmus.

Cardiac: JVP is 2 cm above the sternal angle with the head of the bed at 30°. PMI in 5th ICS in mid-clavicular line. Carotid pulses are 2+ bilaterally without bruits. Regular rate and rhythm (RRR). S1 and S2 are distinct with no murmurs, S3 or S4. No splitting of S2 or friction rubs appreciated.

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

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

Abdomen: Abdomen flat and symmetric with no 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. No hepatosplenomegaly to palpation, no CVA tenderness appreciated.Female Genitalia: External genitalia without erythema or lesions. Vaginal mucosa pink without inflammation, erythema or discharge. Cervix parous (or multiparous), pink, and without lesions or discharge. No cervical motion tenderness. Uterus anterior, midline, smooth, non-tender and not enlarged. No adnexal tenderness or masses noted. No inguinal adenopathy.