Name: Mr. S

Sex: Male

Address: Bronx, NY

Date of Birth: 3/19/1941, 80 years old

Date & Time: 6/7/21, 11:30 AM

Location: Metropolitan Hospital, Emergency Dept, Harlem, NY

Religion: Christian

Marital Status: Divorced

Race: African American 

Source of Information: Self

Reliability: Reliable

Source of Referral: Self

Chief Complaint: “My back hurts” x 3 months

History of Present Illness:

80 year old African American male with no known PMH presents to Metropolitan Hospital ED c/o lower back pain for the past 3 months. He states that the pain began insidiously, around the time that he retired from his job as a superintendent, and has been gradually worsening, especially over the last 2 weeks. He describes the pain as “sometimes sharp, sometimes dull”, and radiating to his abdomen. It is alleviated by sitting still and aggravated by walking, and he can only walk a few steps before the pain gets too severe. He rates the pain as a 5/10 when he sits and a 9/10 when he walks, and states he has never had this severe pain before. He denies taking any medications for the pain or using any ice or heat. In addition to the back pain, he admits to generalized fatigue, SOB after walking a few steps, recent loss of appetite, non-bloody diarrhea about 5 times a day and through the night, nocturia, polyuria, urgency, frequency, and weight loss of about 10 pounds over the last 3 months. He has not seen a doctor in 40 years. He denies hematuria, dysuria, hesitancy, abdominal pain, nausea, vomiting, constipation, chest pain, headache, dizziness, fever, chills, or SOB when sitting still.

Past Medical History:

Present medical illnesses – none that he knows of, hasn’t seen a doctor in 40 years

Past Illnesses- none

Childhood illnesses – none

Immunizations – not up to date

Screening Tests- none

Blood Transfusions- none

Past Surgical History: none

Medications-none

Allergies:

No known food, drug, or environmental allergies.

Family History:

Mother- Died of unknown cancer at age 84

Father – Died of colon cancer at age 102

Son- 56- Alive and Well

Daughter- 52- Alive and Well

Daughter- 49, Alive and Well

Son- 42, Alive and Well

Maternal/paternal grandparents – Deceased at unknown age and unknown reasons

Social History:

Mrs. C is a divorced male, living alone on the ground floor of a walk-up apartment building. He was the superintendent of the building and retired 3 months ago.

Habits – Patient drinks 7-8 beers on the weekends. Denies drinking caffeine, smoking, use of e-cigarettes or any illicit drug use. 

Travel- Denies any recent travel.

Safety- Admits to wearing seat belt.

Sleep – Admits that he does not sleep well since he awakens frequently to go to the bathroom. He usually takes naps during the day.

Exercise – States that he used to exercise a lot due to his work as a super in a walk up apartment, since he had to walk to different apartments a lot to help people out. Recently, he does not exercise as much and gets short of breath after taking a few steps.

Diet- Patient states he has a reduced appetite recently, and eats a few pieces of cake and milk in the morning and a few pieces of chicken fingers at night.

Sexual History: Patient denies currently being sexually active. Denies history of sexually transmitted infections.

Review of Systems:

General – Admits to recent weight loss of about 10 pounds, and fatigue. Denies fever, chills, or night sweats.

Skin, hair, nails –Denies changes in texture, excessive dryness or sweating, discolorations, pigmentations, moles/rashes, pruritus or changes in hair distribution.

Head – Denies dizziness, headaches, vertigo or head trauma, unconsciousness, head fracture or coma.

Eyes –Admits to use of reading glasses Denies use of contacts, visual disturbances, fatigue, lacrimation, or photophobia.

Ears –Denies tinnitus, ear pain, hearing loss, discharge, or use of hearing aids.

Nose/sinuses – Denies discharge, obstruction or epistaxis.

Mouth/throat –Denies sore throat, sore tongue, bleeding gums, mouth ulcers, voice changes.

Neck – Denies localized swelling/lumps or stiffness/decreased range of motion

Pulmonary system – Admits dyspnea on exertion. Denies dyspnea, cough, wheezing, orthopnea, paroxysmal nocturnal dyspnea, cyanosis or hemoptysis.

Cardiovascular system –Admits to hypertension and edema/ swelling of the ankles/feet. Denies chest pain, palpitations, irregular heartbeat, syncope or known heart murmur.

Gastrointestinal system –Admits to loss of appetite, diarrhea, and abdominal pain. Denies intolerance to foods, nausea, vomiting, constipation, dysphagia, pyrosis, flatulence, eructation, jaundice, hemorrhoids, rectal bleeding, or blood in stool. 

Genitourinary system – Admits to urinary frequency, urgency, polyuria, and nocturia. Deniesoliguria, incontinence, dysuria, hesitancy, dribbling, or flank pain.

Musculoskeletal system – Denies muscle/joint pain, arthritis, deformity or swelling, or redness.

Nervous System– Denies seizures, loss of consciousness, ataxia, loss of strength, change in cognition / mental status / memory, or asymmetric weakness.

Peripheral vascular system –  Denies intermittent claudication, coldness or trophic changes, varicose veins, peripheral edema or color changes.

Hematological system – Denies anemia, easy bruising or bleeding, lymph node enlargement, or history of DVT/PE.

Endocrine system –Admits to polyuria. Denies polyphagia, polydipsia, heat or cold intolerance, excessive sweating, hirsutism, or goiter.

Psychiatric –Admits to occasional depression/sadness over the past few months, but denies feeling depressed currently. Denies anxiety, OCD or ever seeing a mental health professional.

 Physical Exam

General: 80 year old male, alert and oriented to person, place and time. Patient is of average build and has good posture, is well dressed, well groomed, and has good hygiene. Patient appears in no apparent distress.

Vital Signs: BP: 109/53, seated                       

R: 16 breaths/min unlabored     

P:95 beats/min, regular       

T: 98.5 Degrees C (oral)                      

O2 Sat: 99% on Room air

Height: 68 inches                Weight: 165 pounds            BMI: 25.1

Skin- Warm and dry, smooth, poor turgor, nonicteric. No lesions, masses, scars, tattoos, thicknesses or opacities.

Hair- average quantity and distribution. Coarse, no lice or seborrhea noted.

Nails- Normal color size and shape of the nails. No spooning, clubbing, beau’s lines fissures, paronychia noted. Capillary refill <2 seconds throughout hands and toes.

Head-Atraumatic, normocephalic. Nontender to palpation on the frontal, temporal, occipital, and parietal areas. No deformities or specific faces noted.

Eyes-Symmetrical OU. Eyebrows and eyelashes even distribution, eyelids have no discharge or swelling, lacrimal glands have no excessive tearing, dryness, enlargement or erythema, lacrimal sac not inflamed or swollen. No evidence strabismus, exophthalmos or ptosis.PERRL, EOMs intact with no nystagmus. 

Ears- Symmetrical and normal size. No lesions, masses or trauma on external ears. No discharge/foreign bodies in external auditory canals AU. Tympanic membrane pearly white/intact with cone of light in normal position AU.

Nose-Symmetrical, no masses lesions or deformities, trauma or discharge. Nares patent bilaterally, nasal mucosa pink & well hydrated. 

Mouth

Lips -Moist; no cyanosis or lesions

Mucosa -Pink, No masses; lesions noted. No leukoplakia.

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

Teeth -all teeth intact, good dentition, no cavities noted.

Gingivae – Pink; moist. No hyperplasia; masses; lesions; erythema or discharge.

Tongue –Pink; moist, well papillated; no masses, lesions or deviation noted.

Oropharynx – Well hydrated; no injection; exudate; masses; lesions; foreign bodies. Tonsils present with no injection or exudate. Uvula pink, no edema, lesions. 

Neck – Trachea midline. No masses; lesions; scars; pulsations noted. Supple; non-tender to palpation.   

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

Thorax & Lungs 

Chest – Symmetrical, no deformities, no evidence of trauma. Respirations are unlabored, no paradoxical respirations or use of accessory muscles noted. Lat to AP diameter 2:1. Non- tender to palpation. 

Lungs – Clear to auscultation and percussion bilaterally. Chest expansion and diaphragmatic excursion symmetrical. No adventitious sounds. 

Abdomen-Abdomen tender to deep palpation over right and left lower quadrants, no guarding or rebound noted. Abdomen flat and symmetric with no striae, scars or pulsations noted. Bowel sounds normoactive in all four quadrants with no aortic/renal/iliac or femoral bruits. No hepatosplenomegaly to palpation, no CVA tenderness appreciated. 

Heart-Normal rate and rhythm. S1 and S2 are distinct with no murmurs, S3 or S4. No splitting of S2 or friction rubs appreciated. Carotid pulses are 2+ bilaterally without bruits.

Mental Status Exam- patient is alert, attentive, and oriented. Speech and language are clear and fluent with good word comprehension. Appears to be in good mood, has insight and judgment in his medical problems. Memory and cognitive ability intact, gave accurate information upon assessment of history.

Peripheral Nervous System-

Motor/Cerebellar-Tender to palpation across lower spine and bilateral lower back. Pain elicited with AROM of hips. Full active/passive ROM of all extremities. Symmetric muscle bulk, slight atrophy, no tics, tremors or fasciculation. Strength 5/5 throughout.

Sensory-Intact to light touch, sharp/dull, and vibratory sense throughout.  

Reflexes-2+ throughout.

Peripheral Vascular Exam- Skin normal in color and warm to touch upper and lower extremities bilaterally.  No calf tenderness bilaterally, equal in circumference, no edema. No palpable cords or varicose veins bilaterally.

Labs/ Testing

Of note: Hb- 4.2

FOBT- positive for occult blood

Assessment

Mr. S is an 80 year old African American male with no known PMH presents to Metropolitan Hospital ED c/o lower back pain for the past 3 months, which has worsened over the past 2 weeks. He also admits to DOE, nocturia, polyuria, urgency, frequency, generalized fatigue, frequent non-bloody diarrhea, loss of appetite and weight loss of 10 pounds in the past 3 months. On physical exam, he is tender to palpation across his lower back, and slightly across his lower abdomen (LLQ/ RLQ). His labs are significant for a hemoglobin of 4, and his FOBT is positive for occult blood.

Differential Diagnoses:

1. Colorectal Cancer– has diarrhea, fatigue, recent weight loss, loss of appetite, lower abdominal pain, positive FOBT suggesting occult blood loss, and very low hemoglobin
2. Prostate Cancer-urinary urgency, frequency, nocturia, polyuria, and back pain. He is also older African American male which increases risk, and complaining of weight loss. Not complaining of hematuria but his hemoglobin is very low, suggesting occult blood loss.
3. Celiac Disease– has diarrhea, fatigue, weight loss, lower abdominal pain, and anemia. Also has back pain which could be caused by celiac due to inflammation. However, denies nausea, vomiting, constipation.
4. Inflammatory Bowel Disease- -has diarrhea, lower abdominal pain, positive FOBT, weight loss and fatigue.
5. Pyelonephritis/ Kidney Disease– has back pain, urgency, frequency, and fatigue. However, symptoms have been going on for a while, and he has no fever/chills/signs of infection, no CVA tenderness. 
6. Diverticulosis-has LLQ abdominal pain/ tenderness, and diarrhea. However, no nausea/vomiting, constipation, or fever.
7. BPH- possibly secondary diagnosis, due to his older age and symptoms or urinary urgency, frequency, nocturia, and polyuria

Problem List/Plan – 

1. Low Hemoglobin/ Hypotension/ Dyspnea on Exertion– Hb 4.2! Feels well, but needs urgent T/S and blood transfusion.
2. Back pain, fatigue, weight loss, diarrhea– CBC, CMP, ESR, transglutaminase antibodies to check for celiac, CT abdomen/ pelvis, if no diverticulosis then colonoscopy to look for IBD/ Celiac/ Cancer
3. Nocturia, polyuria, oliguria– urinalysis to check for pyelonephritis/ other infection, PSA antigen, digital rectal exam, transrectal ultrasoundà consider MRI/ biopsy if strongly suspecting prostate cancer
4. Occasional Depression/ Sadness– social work consult
5. Alcohol Use– admits to drinking 7-8 beers on the weekends. Educate about harms associated with significant alcohol drinking.