Medhat Nan

History

Identifying data:

Patient name: Mrs. MK

Address: Queens, NY

Location: Jamaica hospital, Queens, NY

Age, Race & Religion : 31 y/o WF, Catholic

Date: September 09,2018; Time: 3:30 PM

Data source: patient 

Referral source: self

Chief Complaint: chest pain x 3 days

History of Present illness:

Mrs. MK is a reliable 31 y/o married, non smoker Egyptian female with no significant PMHx presents to the ED c/o chest pain for the last 3 days. She states that the pain started suddenly in the upper left side of her chest and doesn’t spread. She describes it as sharp pain that comes and goes, 5 out of 10 in severity on a scale of 1-10 with 10 being the worst, and it gets better when she takes OTC ibuprofen, or with shallow breathing, but it gets worse with deep breath. She also states that she has a mild dry cough that started 3 days ago. The cough occurs randomly, nothing makes it better or worse, she tried OTC Robitussin DM, but didn’t help, no hemoptysis. She denies any trauma to her chest, or involvement in any strenuous activities. She states a week ago she had flu that remained for 2 day and relieved with rest, hot fluids, and OTC Alka-seltzer plus. The patient denies having fever, chills, night sweats, loss of weight ,Orthopnea, PND, dyspnea on exertion, wheezing, cyanosis,palpitations or leg swelling . She also denies nausea , vomiting h/o traveling or contact with sick people. The patient states that she hasn’t seen any Clinician for this pain and had no similar pain in the past. She doesn’t know what is causing her pain, and she says the pain has limited effect on her in doing her daily activities.

Past Medical History:

Severe gastroenteritis and dehydration that required hospitalization for 2 days  in 2006. She also has been told by her mother that she had a viral croup at age 2 that required hospitalization for 1 day. The patient unable to recall hospitals names. Otherwise, no childhood illnesses. Her immunizations are up to date; Flu vaccine yearly. Her last Pap smear in 2017.

Past Surgical History:

She underwent 3 C-Sections: 2 in Egypt in 2007, and 2009, she unable to recall hospitals names, and 1 here at Jamaica hospital in Queens in 2013. All operations healed without complications. No h/o injuries or blood transfusions.

Medications: see HPI, the patient doesn’t know the doses, and she is taking them as needed.

Allergies: NKDA, no allergies to cats and tree pollen. No h/o of food or environmental allergies.

Family History :

Parents: Mom is 56 y/o with diabetes at age 40. Dad alive and well.

She has 3 kids, all of them alive and well.

She has 2 siblings- 33 and 28, alive and well.

Maternal/paternal grandparents. Deceased at unknown age & unknown reasons.

No family history of heart diseases, cancer, or hypertension.

Social History:

Mrs. MK, married, living with her husband and her 3 kids. She works as a teacher assistant. She doesn’t smoke, use illicit drugs, drink alcohol or caffeinated drinks.

She eats healthy food, and goes to gym 5 days/week to do exercises for 1 hour each day.

Traveling and safety measures. She denies any h/o recent travels ; She always use safety belt.

Sexual History: she is sexually active with her husband, no condoms.

Review Of Systems (ROS):

General- see HPI.

 

Skin, hair, nails – Denies changes in texture, excessive dryness or sweating, discolorations, pigmentations. she admits she is having 2 skin tags with no changes in their (ABCDEs).She denies moles/rashes, pruritus or changes in hair distribution.

 

Head – Denies headaches, vertigo or head trauma.

 

Eyes – denies allergies to cats & pollen. Denies other visual disturbances, or photophobia. She wears contact lenses. Last eye exam 2008– does not know her visual acuity; normal pressure.

 

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

 

Nose/sinuses – Denies discharge, obstruction or epistaxis.

 

Mouth/throat – Denies bleeding gums, sore tongue, sore throat, mouth ulcers, voice changes or use dentures. Last dental exam 2018 and was normal.

 

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

 

Breast – Denies lumps, nipple discharge, or pain.

 

Pulmonary system –see HPI.

 

Cardiovascular system – see HPI, no known heart murmur.

 

Gastrointestinal system – Has regular bowel movements daily. Denies change in appetite, intolerance to specific foods, nausea, vomiting, dysphagia, pyrosis, unusual flatulence or eructations, abdominal pain, diarrhea, jaundice, hemorrhoids, constipation, rectal bleeding, or blood in stool.

 

Genitourinary system – Denies urinary frequency or urgency, nocturia, oliguria, polyuria, dysura, incontinence, awakening at night to urinate or flank pain.

 

OB/GYN – See Past Surgical History. G4T3P0A1L3. Menarche age 14. LMP. 2weeks ago. Her period is regular, average (2 pads/day), and lasts for 4 days. Denies breakthrough bleeding/spotting or vaginal discharge.

 

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

 

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

 

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

 

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

 

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

 

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