Nicholas Burney H&P #1 Pre admission Testing
Identifying Data:
Full Name: M.R.
Address: Jamaica, NY
Date of Birth: March 9th, 1951
Date & Time: October 8th, 2010
Location: NYP Queens, Jamaica
Religion: Catholic
Source of Information: Self
Reliability: Good
Source of Referral: PCP
Mode of Transport: Self
Language: Spanish only
Vital Signs :
BP 124/75 Right Arm
120/70 Left Arm
Pulse: 66 bpm
Respiratory rate : 14 rpm
SpO2 96%
Height: 4’9”
Weight: 151 lbs
Chief Complaint: “I’m getting cleared to get a hysterectomy”
History of Present Illness:
MR is a 68yo woman to be cleared for a hysterectomy and bilateral oophorectomy on October 15th. Pt had severe cramping in the abdomen w/ 9/10 pain along with hematuria and incontinence in January. Urologist confirmed pre-cancerous polyps of the cervix in April and they were removed along with pre-cancerous fibroid transvaginally on August 12th.
Past Medical History: Hypothyroidism, Hematuria, Incontinence, Hyptercholesterolemia
Past Surgical History: Fibroid removal Aug 12th, 2019, appendectomy and cholecystectomy – remote, C-section -remote
Allergies: No known medical allergies, environmental, or food allergies
Medications: Levothyroxine 100mcg – 1 tablet daily PO, Symbastatin 20mg – 1 tablet daily PO in evening, Oxybutynin 5mg – 1 tablet daily PO
Social History: Lives with husband, non-smoker, non-drinker, non-substance user
Family History: Father deceased, cause unknown, Mother – 98 yo A+W, 3 daughters A+W
Sexual History: No history of STIs, not sexually active
Review of Systems :
General : Admits age related weakness, fatigue. Denies fever, chills, night sweats, change in weight or appetite
Skin, Hair, Nails : Denies change in texture, excessive dryness or sweating, discolorations, pigmentations, moles, rashes, pruritus, change in hair distribution
Head : Denies headache, trauma, unconsciousness, coma, fracture, vertigo
Eyes : Wears glasses. Denies visual disturbances, fatigue, photophobia, pruritus, lacrimation,
Ears : Denies deafness, pain, discharge, tinnitus, hearing aids
Nose/Sinuses : Denies discharge, epistaxis, obstruction,
Mouth/Throat : Denies bleeding gums, sore tongue, sore throat, mouth ulcers, voice changes, dentures,
Neck : Denies lumps, swelling, stiffness, decreased range of motion
Breast : Denies lumps, nipple discharge, pain. Last mammogram July 2019
Respiratory : Denies dyspnea, shortness of breath, wheezing, hemoptysis, cyanosis, cough, orthopnea, paroxysmal nocturnal dyspnea
Cardiovascular : Denies chest pressure, HTN, palpitations, irregular heartbeat, edema, syncope
Gastrointestinal : Denies change in appetite, abdominal pain, intolerance to specific foods, nausea, vomiting, dysphagia, pyrosis, flatulence, eructations, diarrhea, hemorrhoids, change in stool caliber, blood in stool. Admits constipation.
Obstetrical History: 3 daughters, 2 miscarriages
Genitourinary : See HPI
Musculoskeletal : Denies muscle pain, joint pain, deformity, swelling, redness, arthritis
Peripheral Vascular : Denies intermittent claudication, coldness or trophic changes, varicose veins, peripheral edema, color change
Hematologic : Denies anemia, easy bruising/bleeding, lymph node enlargement, history of DVT/PE
Endocrine : Denies polyuria, polydipsia, polyphagia, heat or cold intolerance, goiter, hirsutism. Hypothyroidism well controlled.
Neurologic : Denies seizures, loss of consciousness, sensory disturbances, paresthesia, dysesthesia, hyperesthesia, ataxia, loss of strength, change in mental status, memory loss, asymmetric weakness
Psychiatric : Denies feelings of helplessness, feelings of hopelessness, lack of interest in usual activities, suicidal ideation. Admits surgery related anxiety and worries.
