Identifying Data:

Name: Mrs. S

Sex: Female

Address: Westbury, NY

Date of Birth: 65 Years Old

Date & Time: 2/11/21

Location: Statcare Urgent Care, Hicksville, NY

Marital Status: Married

Race: White

Source of Information: Self

Reliability: Reliable

Source of Referral: Self

Mode of Transport: Car

Chief Complaint: “I have pain in my back” x 3 days

History of Present Illness:

Mrs. S is an obese female with a significant medical history of GERD recent history of COVID-19 presenting to the Statcare Urgent Care complaining of upper back pain and shortness of breath for the past 3 days. She was diagnosed with COVID-19 on January 25^th and recovered, and just returned to work four days ago. Of note, her COVID-19 symptoms included a cough, fever, and fatigue. She said the pain began gradually while she was at work and has been progressively worsening. She described the pain as dull and non-radiating in the middle of her upper back deep to her spine, at the level of T3-T4, and is constant. The pain is aggravated by lying flat on her back so she has difficulty sleeping and has to sleep sitting up, and is alleviated by rest and walking. She rated the pain as an 8/10, and admitted to taking Tylenol for the pain, which provided slight relief. She states that she has never had this type of pain before. She also admitted to having dyspnea, fatigue, and lethargy. She denied current cough, wheezing, headache, dizziness, lightheadedness, fever, chills, body aches, chest pain, nausea, vomiting, or diarrhea.

Past Medical History:

Present medical illnesses – Gastroesophageal Reflux Disease

Past Illnesses- None

Childhood illnesses – none

Immunizations – Up to date

Screening Tests- none

Blood Transfusions- none

Past Surgical History:

None

Medications:

Omeprazole 20 mg qd, for GERD, last dose yesterday

Allergies:

No known food, drug, or environmental allergies.

Family History:

Mother – Alive and Well

Father – Deceased at unknown age and unknown reasons

Social History:

Mrs. L is a married woman who lives at home with her husband. She works as an accountant

Habits- Patient drinks one cup of coffee a day. Denies past and present use of alcohol, cigarettes, tobacco, e-cigarettes, illicit drug use, and history of substance abuse.

Travel- Denies any recent travel.

Safety- Admits to wearing seat belt.

Sleep – Admits to difficulty sleeping due to back pain.

Exercise – States that she does not exercise frequently.

Diet- Patients maintains a balanced diet.

Sexual History: Heterosexual, monogamous.

Review of Systems:

General –Admits to fatigue. Denies loss of appetite, recent weight loss or gain, generalized weakness, fever, chills, or night sweats.

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

Eyes –Denies use of glasses, contacts, visual disturbances, fatigue, lacrimation, photophobia, and pruritus.

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

Nose/sinuses – Denies discharge, obstruction or epistaxis, sinus pain or pressure.

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

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

Breast- Denies lumps, nipple discharge, and pain.

Pulmonary system – Admits to shortness of breath and dyspnea. Denies cough, wheezing, orthopnea, paroxysmal nocturnal dyspnea, cyanosis or hemoptysis.

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

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

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

Nervous System– Denies seizures, loss of consciousness, sensory disturbances such as numbness, paresthesia, dysesthesias, hyperesthesia, 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 –Denies polyuria, polyphagia, polydipsia, heat or cold intolerance, excessive sweating, hirsutism, or goiter.

Psychiatric –Denies anxiety, depression/sadness, OCD or ever seeing a mental health professional.

Physical Exam

Vital Signs:      BP: 128/78

R: 16 breaths/min unlabored     

P: 85 beats/min, regular       

T:97.3 degrees F (oral)                      

O2 Sat: 96% on Room air

Height: 65 inches               Weight: 200 pounds        BMI: 33.28

General: 57 year old obese female, alert and oriented to person, place and time. Patient has good posture, is well dressed, well groomed, has good hygiene, and appears in no acute distress.                  

Skin- Warm and moist, smooth, good 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.

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. Sclera white, conjunctiva ad cornea clear. 

Visual acuity uncorrected – 20/20 OS, 20/20 OD, 20/20 OU

Visual fields full OU. PERRLA, EOMs intact with no nystagmus. 

Fundoscopy – Red reflex intact OU. Cup to disk ratio <0.5 OU. No evidence of AV nicking, hemorrhages, papilledema, exudates, cotton wool spots or neovascularization OU. 

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. Auditory acuity intact to whispered voice AU. Weber midline/Rinne reveals AC>BC AU.

Nose-Symmetrical, no masses lesions or 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 and maxillary sinuses. 

Mouth

Lips – Pink, moist; no cyanosis or lesions. Non-tender to palpation.

Mucosa – Pink; well hydrated. No masses; lesions noted. Non-tender to palpation. No leukoplakia.

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

Teeth – Good dentition and no obvious dental caries noted.

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

Tongue – Pink; 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.   2+ Carotid pulses, no thrills, bruits noted bilaterally, no lymph nodes appreciated.

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

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. Tactile fremitus intact throughout. No adventitious sounds. 

Breast Exam –Breasts symmetric, no dimpling, no masses to palpation; nipples symmetric without discharge or lesions. No axillary nodes palpable.  

Abdomen-Abdomen flat and symmetric with some striae, no scars or pulsations noted. Bowel sounds hyperactive in all four quadrants with no aortic/renal/iliac or femoral bruits. Non-tender to palpation throughout the right and left lower quadrants, tympanic throughout, no guarding or rebound noted. 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. JVP is 2.5 cm above sternal angle with the head of the bed at 30 degrees. PMI in 5th ICS in mid-clavicular line and not greatly appreciated.  

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

Cranial Nerve Exam – CN I- correctly identifies coffee and mint odors bilaterally

CNII-visual fields full by confrontation, visual acuity 20/30 OD, 20/30 OS, 20/30 OU, uncorrected, red reflex present, no hemorrhages, exudates, or crossing phenomena

CN III, IV, and VI- extraocular movements intact, PERRLA, no ptosis

CN V- face sensation intact bilaterally, corneal reflex intact, jaw muscles strong without atrophy

CN VII- correctly identified sweet, salt, bitter and sour tastes, facial expressions intact, clearly enunciates words

CN IX and X- no hoarseness, uvula midline with elevation of soft palate, gag reflex intact, no difficulty swallowing

CN XI- full range of motion at neck with 5/5 strength and strong shoulder shrug

CN XII- tongue midline without fasciculations, good tongue strength

Peripheral Nervous System-

Motor/Cerebellar-Full active/passive ROM of all extremities without rigidity or spasticity. Symmetric muscle bulk with good tone. No atrophy, tics, tremors or fasciculation. Strength 5/5 throughout.  Romberg negative, no pronator drift noted. Gait steady with no ataxia. Tandem walking and hopping show balance intact. Coordination by rapid alternating movement and point to point intact bilaterally, no asterixis

Sensory-Intact to light touch, sharp/dull, and vibratory sense throughout.   Proprioception, point localization, extinction, stereognosis, and graphesthesia intact bilaterally

Reflexes-2+ throughout, negative Babinski, no clonus appreciated

Meningeal Signs-No nuchal rigidity noted. Brudzinski’s and Kernig’s signs negative

Peripheral Vascular Exam- Skin normal in color and warm to touch upper and lower extremities bilaterally.  No calf tenderness bilaterally, equal in circumference.  Homan’s sign not present bilaterally. No palpable cords or varicose veins bilaterally. No palpable inguinal or epitrochlear adenopathy. No cyanosis, clubbing / edema noted bilaterally.

Musculoskeletal: No soft tissue swelling / erythema / ecchymosis / atrophy / or deformities in bilateral upper and lower extremities. Non-tender to palpation / no crepitus noted throughout. FROM (Full Range of Motion) of all upper and lower extremities bilaterally.  No evidence of spinal deformities.  

Assessment – Mrs. S is a reliable, 57 year old female with a significant medical history of GERD and recent history of COVID-19. She presents to Statcare Urgent Care complaining of worsening upper mid-back pain and shortness of breath that started 3 days ago.

Plan:

Problem List:

1. Back Pain- non-tender to palpation upon exam. Refer for Chest X-ray
2. Shortness of Breath/ Dyspnea- refer for spirometry, EKG, and Chest X-ray/ CT scan
3. Fatigue- common post-COVID symptom, encourage increased rest.
4. Obesity- educate patient on risks associated with obesity, educate about diet and exercise interventions, refer to nutritionist.
5. GERD- symptoms well-controlled with current medication. Continue taking medication.

Differential Diagnosis

1. Pulmonary Embolism- patient recently recovered from COVID, a risk factor for clotting disorders, and is presenting with SOB. Also, works as an accountant where is sitting all day. However, denies history of DVT, tachycardia, chest pain, palpitations, or lightheadedness.
2. Pneumonia- patient recently recovered from COVID and presents with upper inner back pain, SOB, dyspnea, and fatigue. However, denies cough, fever, chills, chest pain, loss of appetite, or nausea/vomiting. 
3. Costochondritis- often comes on after minor trauma or upper respiratory illness- patient recently recovered from COVID where was coughing a lot. Presents with inner back pain, dyspnea. However, denies tenderness when pressing on rib joints.
4. Muscle Strain- patient has upper back pain, SOB, and dyspnea. However, does not have increased pain when moving body in different directions.
5. Vertebral Compression Fracture- patient complains of back pain. However, denies history of trauma, tenderness upon palpation, numbness, tingling, or limited mobility, and has increased, not decreased, pain when lying on back.