Full Name: AS
Sex: M
Address: Elmont, NY
Age: 42 Y/O
Date & Time: 03/09/2021 9:00 AM
Location: CitiMed JFK
Religion: Denies
Marital Status: Married
Race: Hispanic
Nationality: American
Source of Information: Self
Reliability: Reliable
Mode of Transport: Self
Chief Complaint: “I have right elbow pain” x2 days
History of Present Illness:
AS is a reliable 42-year-old Hispanic male who presents to the clinic complaining of right elbow pain for x2 days. He works at Allied Aviation at JFK as a flight fueler. He states that on 03/07/21 he was at work fueling a flight and he had to reel in the metal gasoline hose (he is unsure of the weight). As he was dragging the hose closer he suddenly felt a sharp pain in his right elbow. The patient continued to reel the hose in and completed the rest of his 6-hour shift. The patient rates his elbow pain as a 6/10 and characterizes it as intermittent, achy, and worse with movement. He describes that the pain radiates to his right forearm. He also admits to weakness in his right extremity. The patient feels better at rest and uses one patch of icy hot in the past two days, with relief. He has not taken any medication for the pain. He denies numbness, tingling, headaches, fever, chest pain, headaches, changes in weight. Patient also denies previous right elbow injuries or chronic pain prior.
Past Medical History:
Present medical illnesses – Denies.
Childhood illnesses – Denies.
Immunizations – Up to date.
Past Surgical History: Denies.
Medications: Denies.
Allergies: Denies environmental, medication and food allergies.
Family History:
Mother – 64, alive and well
Father – 65, alive and well
Maternal/paternal grandparents – Deceased at unknown age & unknown reasons
Denies family history of cancer, diabetes and cardiovascular disease
Social History:
AS is a married male living at home with his wife. He is a flight fueler at JFK for Allied Aviation.
Habits – Pt drinks cup of coffee a day. Denies past and present use of cigarettes, tobacco, e-cigarettes or vaping. Pt denies the use of any illicit drugs, a history of substance abuse.
Travel- AS denies any recent travel.
Safety- AS admits to wearing seat belt.
Sleep – AS admits to having very good night sleeps.
Exercise – AS exercises and lifts weights two times a week.
Diet- Maintains a healthy diet and makes dinner his largest meal.
Review of Systems:
General – Denies loss of appetite, recent weight gain or loss, generalized weakness/fatigue, fever, headaches, 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, head fracture or coma.
Eyes –Denies contacts or glasses, visual disturbances, fatigue, photophobia, and pruritus. Last eye exam x1 year ago- normal.
Ears –Denies deafness, tinnitus, pain, discharge, or use of hearing aids.
Pulmonary– Denies dyspnea, DOE, cough, wheezing, orthopnea, paroxysmal nocturnal dyspnea, cyanosis and hemoptysis.
Cardiovascular–Denies chest pain, swelling of the extremities, irregular heartbeat, syncope or known heart murmur.
Nervous – Denies seizures, loss of consciousness, sensory disturbances, ataxia, loss of strength, change in cognition / mental status / memory, or weakness.
Musculoskeletal system – Admits to right elbow pain and right forearm pain. Denies 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 – Denies anemia, easy bruising or bleeding. Denies 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
General: Proper lighting and draping of the Pt. Patient was well-groomed, appears to have good hygiene, average build and moderate posture. Patient does not appear to be in acute distress. Pt is alert and oriented x3.
Vital Signs: BP: R L
Seated 138/76 132/74
Supine 136/76 136/78
R: 14 breaths/min unlabored P: 68 beats/min regular
T: 98.2 degrees F (temporal) O2 Sat: 98% Room air
Skin:
Skin was warm, smooth, mild turgor, nonicteric, no lesions, masses, scars, tattoos, thicknesses or opacities.
Head
Atraumatic, normocephalic. No tenderness or pain on the frontal, temporal, occipital, or parietal areas. No deformities or specific faces noted.
Musculoskeletal
Right elbow – No ecchymosis, edema, erythema, bleeding, discharge or deformities. Tender over the right lateral epicondyle. No right medial epicondyle or olecranon tenderness. Full ROM with discomfort.
Full ROM all other extremities. Strength – 5/5 both upper and lower extremities.
Sensory– Intact to light touch, sharp and dull
Peripheral Vascular Exam
The extremities are normal in color, size and temperature. Peripheral pulses are 2+ bilaterally.
Neurological
Mental Status = A/O to person place and time. Memory and attention intact. Receptive and expressive abilities intact; thought coherent. No dysarthria, dysphonia or aphasia noted.
Cranial Nerves
II, III, IV, VI –> see physical exam
V–> Normal sensation. Masseter muscles and temporalis muscles intact
VII–> Able to wrinkle forehead, smile, and close eyes normally
VIII –> Hearing loss intact and equal bilaterally
IX and X –> Palate rises equally and uvula is midline
XI –> Normal shoulder shrug and SCM muscle
XII –> Tongue is midline and normal movements.
Summary Statement: AS is a reliable 42-year-old Hispanic male who presents to the clinic complaining of right elbow pain for x2 days.
Assessment:
- Fracture of the right elbow
- Tear of the ligaments/tendons by the right elbow
Plan:
- Get Xray of the right elbow to r/o fx,
- MRI of the right elbow to r/o tear,
- ACE 4 inch to apply to right elbow
- OTC Tylenol, Arnica gel and ICY HOT prn
- PT 3 times a week for 4 weeks to decrease the pain and improve ROM.
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