History and Physical – Hospital Visit 6

Identifying Data
November 9, 2021 – 10:50am
MJ, 35M, African American, Married, Queens, NY
Informant: Self, reliable
Referral Source: Self

Chief Complaint: “I’ve had these bumps on my neck and butt for a while and they weren’t getting better, so I came in”

History of Present Illness:

MJ is a 35-year-old COVID negative male with a history of ESRD currently on dialysis MWF (last dialyzed on 11/08), afib, HTN, HLD, GERD, hidradenitis, and sleep apnea who presented to the ED for a worsening left mandibular abscess for approximately 2 months. He was given a 7day dose of clindamycin one month ago from his PCP, which he took as prescribed without improvement, and its progressive growth prompted his trip to the ED. Patient states that he has also noticed multiple abscesses on his left buttock over the last month that have become irritable when sitting. Patient reports multiple similar episodes in the past, most recently a right buttock abscess in 2020 which required drainage. Denies any associated trouble swallowing, painful chewing, fever, chills, dyspnea, shortness of breath, or headache.

Past Medical History:

  • ESRD on hemodialysis M/W/F since 01/2020
  • Atrial fibrillation x3years
  • GERD x4years
  • HTN x6years
  • Hyperlipidemia x6years
  • Hidradenitis Suppurativa x10years
  • Obstructive Sleep Apnea x15years
  • Influenza vaccine 09/2021
  • Pfizer COVID vaccine second dose 04/2021

Past Surgical History:

  • Abscess Drainage Right buttock – age 34, no complications
  • AV Fistula Placement left arm – age 33, no complications
  • Abscess Drainage Axillary Region – age 23, no complications
  • Abscess Drainage Groin Region – age 21, no complications
  • Denies eye, hernia, appendix, or gallbladder surgeries


  • Ampicillin-Sulbacktam (Unasyn) 3g IV q24h (Started during admission)
  • Apixaban (Eliquis) 5mg PO BID
  • Atorvastatin (Lopitor) 10mg PO nightly
  • Carvedilol (Coreg) 25mg PO BID
  • Dronedarone (Multaq) 400mg PO BID
  • Epoetin Alfa-epbx (Retacrit) 10,000U SC weekly
  • Ergocalciferol (Vitamin D2) 50,000U PO weekly
  • Pantoprazole (Protonix) 40mg PO QD before breakfast
  • Sevelamer Carbonate (Renvela) 800mg PO TID


  • NKDA, no food/environmental allergies

Family History:

  • Father: Deceased (45) from CKD
  • Mother: Deceased (48) from Hypertensive cardiovascular disease

Social History: MJ is a married male living with his wife and two children and is currently a sanitation enforcement agent for DSNY.

  • Diet: Denies following any diet regimen.
  • Smoking: Denies use of any tobacco products.
  • Alcohol: Denies drinking any beer, wine, or liquor.
  • Drugs:  Denies use of any illicit drugs.
  • Sleep: Sleeps 7-8 hours/night using 2 pillows. Denies use of a CPAP device
  • Travel: Trip to Las Vegas 10/21, no sick contacts
  • Exercise: Denies exercise.
  • Sexual History: Sexually active with his wife, does not use any protection. No history of STIs

Review of Systems:

General: Denies any recent weight loss or gain, loss of appetite, generalized weakness or fatigue, night sweats, fever, or chills

Skin, hair, and nails: SEE HPI. Denies any excessive dryness, sweating, discolorations, pigmentations, moles/rashes, or changes in hair distribution

Head: Denies headaches, migraines, vertigo, nausea, or vomiting.

Eyes: Denies corrected vision. Denies visual disturbances, double vision, blurriness, excess tearing or dryness, photophobia, or pruritis. Last eye exam over 5 years ago.

Ears: Denies hearing loss, tinnitus, vertigo, discharge, earache.

Nose and sinuses: Denies discharge, obstruction, allergies, or epistaxis

Mouth and throat: Denies bleeding gums, ulcerations, or sore throat. Does not wear dentures. Last dental exam 05/2021.

Neck: See HPI

Pulmonary: Denies SOB/DOE, cough, or wheezing.

Cardiovascular: Denies chest pain, palpitations, edema, irregular rhythms.

Gastrointestinal: Has formed brown bowel movements daily with no changes in color or consistency. Denies changes in appetite, intolerance to any foods, no nausea/vomiting/dysphagia, pyrosis. No constipation, bleeding, (hemorrhoids, melena, or hematochezia), or abdominal pain. Colonoscopy scheduled 12/2021.

Genitourinary: Denies incontinence, dysuria, nocturia, urgency, oliguria, or polyuria

Nervous: Denies seizures, headache, loss of consciousness, sensory disturbances, ataxia, loss of strength, change in cognition/mental status/memory, or weakness

Musculoskeletal: Denies joint pain, swelling, weakness, changes in range of motion, or instability.

Peripheral Vascular: Denies peripheral edema, intermittent claudication, or varicose veins.

Hematologic: Denies easy bruising or bleeding and lymph node enlargement. No history of DVT/PE. Denies ever receiving blood transfusion.

Endocrine: Denies heat/cold intolerance, excessive sweating, diabetes.

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

Physical Exam:

General: 35M, A&O x3, sitting up in hospital bed, gowned, neatly groomed, does not appear in distress.


  • BP(Seated): R – 108/68 (AV Fistula on L)
  • P: 80bpm, regular
  • R: 20breaths/min, unlabored
  • T: 98.8F (37.1C), oral
  • O2 Sat: 95% RA
  • Height: 69 inches – Weight: 281lbs – BMI: 41.5 – Obese

Skin: Warm and moist with good turgor throughout. Nonicteric. Left buttock multiple indurations covering approximately 10cm x 10cm with fluctuance. No erythema or warmth. Nontender on palpation. Area was demarcated by RN with a surgical blue pen

Hair: Average quantity and distribution.

Nails: No clubbing, capillary refill <2 seconds in all four extremities

Head: Normocephalic, atraumatic, nontender to palpation throughout.

Eyes: Symmetrical OU. No strabismus, exophthalmos, sclera white, cornea clear, conjunctiva pink.

  • Visual uncorrected – 20/30 OS, 20/40 OD, 20/30 OU
  • Visual fields full OU.  PERRLA, EOMs intact with no nystagmus 
  • Fundoscopy – Red reflex intact OU.   Cup to disk ratio< 0.5 OU.  No AV nicking, hemorrhages, or exudates

Ears: Symmetrical and appropriate in size. No masses, lesions, or deformities on external ears.  No discharge or foreign bodies in external auditory canals AU. TM’s white and intact with light reflex in good position AU.  Auditory acuity intact to whispered voice AU.  Weber midline.  Rinne reveals AC>BC AU.

Nose: Symmetrical with no masses, lesions, deformities, trauma, or discharge.   Nares patent bilaterally / Nasal mucosa pink & well hydrated. No discharge noted on anterior rhinoscopy.  Septum midline without lesions, deformities, foreign bodies, or perforation.

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


  • Lips: Pink and moist with no lesions
  • Mucosa: Pink with no masses or lesions. Non-tender to palpation. No leukoplakia.
  • Palate: Intact with no masses or lesions Non-tender to palpation; continuity intact. 
  • Teeth: Good dentition with no obvious dental caries noted.
  • Gingivae: Pink. No hyperplasia; masses; lesions; erythema or discharge.
  • Tongue: Pink; well papillated with no masses or lesions. Non-tender to palpation.
  • Oropharynx: Well hydrated, no masses, lesions, or foreign bodies. Grade 1 tonsils, class II Mallampati score. Uvula pink, no edema

Neck: Trachea midline. Upper left mandibular induration approximately 8cm x 5cm with fluctuance and central punctation. No erythema and nontender to palpation. 2+ Carotid pulses, no stridor, thrills, or bruits noted bilaterally.

Thyroid: Nontender to palpation, no masses, no bruits noted. No thyromegaly.

Chest: Symmetrical, no deformities or trauma. Respirations unlabored, no paradoxical respirations or use of accessory muscles noted. Non-tender to palpation throughout.

Lungs: Clear to auscultation and percussion bilaterally. Chest expansion and diaphragmatic excursion symmetrical. Tactile fremitus symmetric throughout. No adventitious sounds.

Heart: JVP is 2.5 cm above the sternal angle with the head of the bed at 30°. PMI in 5th ICS in mid-clavicular line. Carotid pulses are 2+ bilaterally without bruits. RRR, S1 and S2 are distinct with no murmurs, S3 or S4.

Abdomen: Abdomen flat and symmetric with striae, no pulsations or scars noted. Bowel sounds normoactive in all four quadrants with no aortic/renal/iliac/femoral bruits.  Non-tender to palpation and tympanic throughout, no guarding or rebound noted. Tympanic throughout, no hepatosplenomegaly to palpation, no CVA tenderness appreciated

Genitalia and Hernias: Circumcised male. No penile discharge or lesions. No scrotal swelling or discoloration. Testes Descended bilaterally, smooth and without masses. Epididymis nontender. No inguinal or femoral hernias noted.

Anus, Rectum, and Prostate: No perirectal lesions or fissures. External sphincter tone intact. Rectal vault without masses. Prostate smooth and non-tender with palpable median sulcus Stool brown and Hemoccult negative


  • Mental Status: Alert and oriented to person, place, and time. Receptive and expressive abilities intact. Thought coherent, no dysarthria, dysphonia, or aphasia. Memory and attention intact excluding during episode.

    Cranial Nerves
    • I – intact, no anosmia
    • II – see eye exam fundoscopy
    • III, IV, VI – PERRLA, EOM intact, no nystagmus
    • V – Facial sensation present and equal bilaterally to light tough and pain, strong contraction of jaw muscles without any fasciculations or atrophy. Corneal reflex intact bilaterally
    • VII – Facial movements symmetrical and without weakness
    • VIII – See ear exam
    • IX, X, XII – No difficulty swallowing, gag reflex intact. Uvula midline, tongue movement intact
    • XI – Should shrug intact, sternocleidomastoid and trapezius muscles strong

  • 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.  Rhomberg 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:
  • Meningeal Signs: No nuchal rigidity noted. Brudzinski’s and Kernig’s signs negative

Peripheral Vascular: Skin normal in color and warm to touch upper and lower extremities bilaterally.  AV fistula placed left arm. 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 or 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.  


35yo male with PMH of ESRD on dialysis M/W/F, afib, HTN, HLD, anemia, OSA presents with abscess on left submandibular area and left buttock for 1-2 months.

Problem List:

  • ESRD
  • Anemia
  • AFib
  • CKD
  • HTN
  • HLD
  • GERD
  • Abscess (Buttock and Submandibular)


  • Buttock Abscess
    • Consult ID regarding I&D with wound culture
    • Continue Unasyn
  • Submandibular Abscess
    • Consult ENT regarding I&D – potentially refer to outpatient ENT
    • CT Neck soft tissues with contract
    • Apply warm compress q4h
    • Continue Unasyn
  • ESRD
    • Consult renal to arrange continued dialysis schedule
  • Anemia
    • Continue EPO 10K SC weekly
  • Afib
    • Continue Apixaban and Dronedarone
  • CKD
    • Continue Renvela
  • HTN
    • Continue Carvedilol
  • HLD
    • Continue Atorvastatin
  • GERD
    • Continue Pantoprazole

Differential Diagnosis: (Include rationalization and how to rule out)

  1. Abscess – superficial nontender induration on submandibular region and buttock.
    1. r/o etiology with US/CT and wound culture upon I&D.

  2. Branchial clef cyst – smooth, non-tender, fluctuant mass found between the external auditory canal and submandibular area with cutaneous punctum
    1. CT with contrast will depict a cystic and enhanced mass in the neck
    1. Fine-needle aspiration is helpful to distinguish a branchial cleft cyst from a malignant neoplasm

  3. Lymphadenitis – enlargement in the submandibular region
    1. CT soft tissues in the neck, and a lymph node biopsy can diagnostically r/o

  4. Bacterial boils – swollen bump in hair-bearing areas with a development of a white tip
    1. Wound culture can indicate infecting agent

  5. Hodgkin Lymphoma – low likelihood from history and PE but severity warrants rule out.
    1. Lymph node biopsy and bone marrow aspiration and biopsy for r/o