History and Physical – Hospital Visit 1

March 23, 2021 – 9:30AM
MK, F, White, DOB 12/8/43, Single, Flushing, NY

Informant: Self, reliable
Referral Source: Self
Chief Complaint: “I have fallen several times at home recently and now I am constipated x 4-5 days”

History of Present Illness:
MK is a 77yo COVID-negative female with a PMH of HTN and surgical history of left mastectomy and left lobe lung resection presented to the ED for frequent falls and constipation x4-5 days. States that she has +LOC during these falls and she recently hit her face. Patient lives alone and reports she cannot care for herself anymore. Patient otherwise denies fever, SOB, chest pain, cough, abdominal pain, N/V, and urinary symptoms.

Past Medical History:

  • HTN x 17 yrs
  • Breast cancer – surgery in 2018
  • Lung cancer – surgery in 2016
  • Cellulitis – diagnosed on admission, previously untreated
  • UTI – diagnosed on admission, previously untreated

Past Surgical History:

  • Left  simple mastectomy, November 2018
  • Left lower lobectomy, May 2016


  • Anastrozole 1mg, PO Q.D
  • Docusate-Senna 2 tablets, PO bedtime
  • Doxycycline 100mg, PO Q12H
  • Enoxaparin 40mg, subcutaneous, Q24H
  • Levaquin 500mg, IV Q.D
  • Metoprolol Tartrate 25mg, PO Q12H


  • Penicillin: hives
  • Sulfamethoxazole: hives
  • Strawberry (Food): hives

Family History:

  • Mother: Deceased (unknown age), HTN, breast cancer
  • Father: Deceased (unknown age), unsure of medical history
  • Brother: 86yo, denies medical history

Social History:

  • Habits:  Denies alcohol use, quit smoking cigarettes 20 years ago with 25-pack year history
  • Travel: Denies any travel in the last 5 years
  • Marital history: Never married, lives alone
  • Occupational history: Retired office job for 15 years
  • Home situation: Lives alone, home aid occasionally comes to assist with shower and cleaning
  • Diet: Coffee, premade frozen foods. On low sodium diet while admitted
  • Sleep patterns: Will not sleep in bed out of fear of falling, sleeps in reclining chair
  • Exercise: Limited – walking around apartment unit
  • Sexual history: No longer sexually active

Review of Systems:

  • General: Admits bilateral leg weakness from sedentary lifestyle. Denies loss of appetite but eating less due to constipation. Denies fever, chills, fatigue, recent weight gain of loss.

  • Skin, Hair, and Nails: Admits rash with erythema on lower right leg. Denies any other changes in texture, dryness, or discolorations.

  • Head: + bruising under left eye from most recent fall. Denies any headaches, vertigo, or lightheadedness.

  • Eyes: Does not use corrective vision, denies any visual disturbances, photophobia.

  • Ears: Admits muffled hearing in left ear due to excessive cerumen. Denies any pain, discharge, tinnitus, or use of hearing aids.

  • Nose/Sinuses: Denies discharge, epistaxis, or obstruction

  • Mouth and Throat: Denies bleeding gums, sore tongue, sore throat, and does not use dentures.

  • Neck: Denies swelling, stiffness, or decreased range of motion.

  • Breast: Denies any lumps, nipple discharge, or pain on right breast.

  • Pulmonary: Denies dyspnea, SOB, dyspnea on exertion, cough, wheezing, cyanosis, orthopnea, PND.

  • Cardiovascular: HTN controlled by medication. Denies chest pain, palpitations, edema, irregular rhythms.

  • Gastrointestinal: Admits severe constipation for 5 days, given docusate-senna on admission. Denies dysphagia, pyrosis, flatulence, abdominal pain.

  • Genitourinary: Foley placed on 3/16 to monitor diagnosed UTI. Denies any dysuria or change in color, or flank pain.

  • Sexual history: Not sexually active, denies history of STIs.

  • Menstrual and Obstetrical: Menopausal for 15+ years. Never pregnant.

  • Nervous: Admits loss of consciousness from falls and weakness on right leg prior to each fall. Denies any seizures, headache, sensory disturbances, change in mental status, or memory loss.

  • Musculoskeletal: Admits bilateral knee pain with activity. Denies history of arthritis.

  • Peripheral Vascular: Admits to intermittent claudication bilateral legs with right > left. Positive erythema on right leg. Denies coldness, varicose veins, edema.

  • Hematologic: Denies history of anemia, blood transfusions, DVT/PE. Visible bruising noted from falls.

  • Endocrine: Denies polyuria, polyphagia, polydipsia, heat/cold intolerance, goiter.

  • Psychiatric: Denies feelings of depression, sadness, anxiety, SI, previously seeing a mental health professional.


General Survey: 77yo female, A&O x3 with a larger build sitting up in bed watching tv and finishing breakfast. Does not appear in any distress.


BP Left ArmRight Arm
  • Pulse: 84bpm, strong, regular
    • EKG obtained from nurse: normal sinus rhythm

  • Respirations: 18breaths/minute, unlabored

  • O2 Sat: 99% on room air

  • Temperature: 36.8C (98.2F) oral

  • Height: 68 inches
  • Weight: 88.2kg (194lb) weighed
  • BMI: 29.5

Skin: Warm and dry, no masses or lesions. Slight erythematous rash on right leg below the knee. Slight bruising under left eye from fall and on left hand from phlebotomy access. Good skin turgor bilaterally.

Nails: No clubbing. Capillary refill < 2 seconds bilaterally on upper and lower extremities

Hair: Average quality and distribution of hair. Negative for seborrhea upon scalp inspection.

Head: Nontender to palpation throughout. Small bump on left frontotemporal region from previous fall. Denies any associative pain.

Eyes: Symmetrical OU. Sclera white, cornea clear, conjunctiva pink.

  • Visual acuity uncorrected: OU: 20/30 OD: 20/40 OS: 20/40
  • Visual fields full OU. PERRLA
  • Fundoscopy: Red reflex intact OS. Patient bothered by light, would not allow exam to continue beyond reflex or at all OD. Would look for a cup to disk ratio < 0.5OU. No AV nicking, hemorrhages, or exudates.

Ears: Symmetrical and appropriate size. No masses, lesions, or trauma on external ear. No discharge but moderate amount of cerumen in left ear. TM’s pearly white / intact with light reflex in good position AU. Auditory acuity intact upon whisper test. Weber was midline. Rinne shows AC > BC AU.

Nose: Symmetrical. No masses, lesions, or trauma. Septum was midline on external inspection.
Patient would not allow for internal inspection of nose. Would look for pink nasal mucosa, no septum deviation, and foreign bodies. No discharge on anterior rhinoscopy

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


  • Lips: Pink and dry, no cyanosis or lesions. Patient would not allow palpation for any of the oral exam as she just finished eating. Would expect non-tender to palpation.

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

  • Palate: Pink; well hydrated.   Palate intact with no lesions; masses; scars.  Non-tender to palpation; continuity intact. 

  • Teeth: Good dentition  with no obvious dental caries noted.

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

Non-tender to palpation.

  • Tongue: Pink; well papillated with no masses or lesions. Non-tender to palpation.


  • Neck: Trachea midline with no masses, lesions, scars, or pulsations noted. Non-tender to palpation.  No stridor noted. 2+ Carotid pulses and no cervical adenopathy noted.

  • Thyroid – Non-tender; no palpable masses; no thyromegaly