Sample H&P Mr

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School

Santa Rosa Junior College *

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75.2A

Subject

Medicine

Date

Apr 3, 2024

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pdf

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7

Uploaded by AdmiralElectronCobra48

6/21/2017 Sample H&P Medical Student H&P 11:00 CC: Mr. Jones is a 72yo white, retired farmer, who presented to the ER because “I fainted 3 times in the last 2 days.” HPI: Mr. Jones was in his usual state of health, which allows him to lead a fairly active life, until 2 days PTA when he was in the kitchen making a sandwich. At that time he felt “dizzy” and found himself on the floor. He described the dizziness as “feeling like he was going to pass out.” He doesn’t remember what happened but thinks he lost consciousness for only a few seconds to minutes. No one was home at the time to witness it. He had a headache after the episode, which he relates to hitting his head. (It has eased off with Tylenol.) Prior to losing consciousness, he did not experience a headache, chest pain, palpitations, or shortness of breath. He was not incontinent. Other than the headache, he felt fine and ate his sandwich once he “came to.” He had a very similar episode the next day while he was sitting down watching TV. He felt like he was going to faint and then became aware that he had missed part of his show. The 3 rd fainting spell occurred this morning as he was getting out of bed. He fell back onto the bed so did not hurt himself. He told his wife what happened and she insisted that he come to the ER. He has not started any new medicines or engaged in any new activities lately. He has not been sick including no N/V/D. He has never had chest pains or been told he has heart disease. He has had vertigo in the past but that was very different from his current “dizziness”. He has not had any change in vision, slurred speech, weakness, numbness, or tingling in the last week. He still likes to ride his tractor and do light farming but is afraid to since these episodes started. He is also afraid to drive as it could happen then and cause an accident.
PMH: 1. COPD- smoked 2 ppd for 40 years, quit 1987. 2. HTN- usually runs 130s/80s, per patient 3. Pneumonia- hospitalized for 3 days in 1996 (received pneumovax then) 4. Osteoarthritis of hips, knees, and hands 5. BCCA- multiple removed from arms and face 6. Gout 7. BPH 8. Diverticulitis 1988- last colonoscopy 2000 w/ 2 polyps 9. Appendectomy 1965 Right inguinal hernia repair 1982 10. Medications 1. lisinopril 20 mg po daily, for HTN 2. Hytrin 5 mg po at bedtime, for BPH 3. ASA 325 mg po daily, for cardioprotection 4. Allopurinol 300mg po daily, for gout prevention 5. Atrovent 2puffs 4 times a day, for COPD 6. Motrin 200mg po 2-3 times a day as needed for arthritis 7. Aleve 1-2 tabs po 2-3 times a day as needed for arthritis 8. Tylenol arthritis 1-2 tabs po 3-4 times a day as needed for arthritis 9. Saw palmetto 2 tabs po daily, for prostate Allergies - sulfa (rash) Adverse drug reactions- codeine (N/V) FHx- Father killed in WWII Mother-HTN and DM, died age 75 of heart attack Sister- 75 and healthy Brother – 70 with heart problems and emphysema Brother- died at 68 of heart attack Son- 47, healthy SHx- Married 50 years this Oct; retired corn and tobacco farmer but still maintains about 3 acres of grazing pasture and a small vegetable garden himself; High School grad; served 1 year in Korea (Army). One son and 3 grandchildren who live nearby. He keeps 2 horses for them but doesn’t ride himself aore. Tobacco- as above, ETOH- 2 beers/day for about 20 years but now only an occasional beer every month; no other drugs; monogamous w/ wife. 10. cromolyn sodium, ophthalmic 4%1-2 drops in each eye 4-6 times/day at regular intervals
ROS - Cough- chronic, mostly in the morning, productive of a small amount of white phlegm low back pain- chronic and worse at the end of the day nocturia- gets up 3-4 times a night, worse over past year PE- Thin, alert, elderly white man with a purple-red nodule above the left eye who is sitting up on the stretcher breathing comfortably and appears neither acutely nor chronically ill. Vitals- T 97.8 BP 105/40, supine, 100/40; standing P 56, regular, supine; 52 standing R 22, unlabored, O2 sat- 93% (RA) Head- 3cm, tender, round, purple-red nodule above left eyebrow, skin intact, no surrounding erythema; Eyes- PERRL; fundi- limited exam secondary to hazy, brown opacities obscuring retina Ears- both ear canals impacted w/cerumen Nose- nares patent w/o edema or D/C Mouth/throat- edentulous, moist mucosa w/o lesions Neck- supple, thyroid nonpalpable, no LAD Back- spine straight w/o point tenderness, lumbar paraspinal muscles tight w/ diffuse tenderness Lungs- hyperresonant, diminished BS throughout, I:E ratio 1:3, no wheezes or crackles CV- carotids 2+ w/o bruits, JVP 5 cm, heart bradycardic, regular S1, S2 w/ II/VI holosystolic murmur at apex radiates to axilla; rad pulses 2+, fem pulses 1+w/ rt bruit, DP 1+ left, nonpalp right Abd- scaphoid, normoactive bowel sounds, soft, NT; liver 7 cm by percussion, spleen nonpalp, no masses or bruits Rectal- normal sphincter tone, brown heme neg stool, large, firm prostate w/o nodules or asymmetry (per ER resident)
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