Identifying Data:

Full Name: ZS

Sex: M

Address: Staten Island, NY

Age: 21 Y/O 

Date & Time: 04/06/21 3:25 pm

Location: SIUH ER

Religion: Denies

Marital Status: Single

Race: Caucasian  

Nationality: American

Source of Information: Self

Reliability: Reliable

Mode of Transport: Self

Chief Complaint: “I have a cyst on my lower back that’s causing me pain” x4 days.

History of Present Illness:

ZS is a reliable 21-year-old Caucasian male who presents to the emergency room complaining of a cyst on his lower back that is causing pain. On Saturday he began to feel a sharp pain in his lower back. He rated the pain as a 7/10, which did not radiate. He has taken 3 warm baths, which makes the pain feel better, but he has not taken any of the pain medication for the pain. He states that the pain increases when he applies pressure to that area. He states that the area feels swollen and raised. He has had 4 recurrent cysts on his lower back that have been drained this year. He went to a colorectal surgeon this past Saturday for evaluation of excision of the tract. While there the patient stated that he felt that he had similar pain to those recurrent cysts. The provider stated that he examined a potential cyst developing but that it was too early for drainage. The pain increased throughout the week and today the patient explained that the pain was painful enough to bring him to the emergency room. The patient admits to a slight fever. He denies chills, nausea, vomiting, any recent travel, or contact with anyone who has been sick.  

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 – 46, alive and well

Father – 50, alive and well

Denies family history of cancer, diabetes and cardiovascular disease

Social History:

ZS  is a single male living at home with his mother and father. He is a student at Wagner College.  

Habits – Pt does not drink coffee. 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- ZS denies any recent travel.

Safety- ZS admits to wearing seat belt.

Sleep – ZS admits to having very good night sleeps.

Exercise – ZS exercises and lifts weights three times a week.

Diet- Maintains a healthy diet and makes dinner his largest meal.

Review of Systems:

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

Nose/sinuses – Denies discharge, obstruction or epistaxis.

Mouth/throat – Denies bleeding gums, denies dentures, sore throat, sore tongue, mouth ulcers, voice changes. Last dental exam x1 years – normal. 

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

Breast- Denies lumps, nipple discharge, and pain.

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.

Gastrointestinal– Admits to recurrent pilonidal cysts. Last cyst and drainage was in December of 2020.  Denies flatulence, eructation, acid reflux and blood in the stool. Denies change in appetite, intolerance to specific foods, vomiting, nausea, constipation, dysphagia, pyrosis, abdominal pain, diarrhea, jaundice, hemorrhoids, rectal bleeding, or blood in stool.

Genitourinary system – Denies urinary frequency, urgency, slight incontinence and nocturia. Denies oliguria, polyuria, dysuria, or flank pain.

Sexual History- Admits to being currently sexually active with his girlfriend. Partners were always female and admits to using condoms as protection. Denies history of sexually transmitted diseases and impotence.

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             116/72          118/72

Supine 114/78            116/76

R:         12 breaths/min unlabored                 P: 70 beats/min regular

T:         100.0 degrees F (temporal)                O2 Sat: 98% Room air

Skin:

Skin was warm, smooth, mild turgor, nonicteric, no lesions, masses, scars, tattoos, thicknesses or opacities.

Nails:

Normal color size and shape of the nails. Has proper capillary refill on both the fingers and toes. No spooning, clubbing, beau’s lines fissures, paronychia noted.

Head

Atraumatic, normocephalic. No tenderness or pain on the frontal, temporal, occipital, or parietal areas. No deformities or specific faces noted.

Hair

Good quantity evenly dispersed. Very coarse and no lice or seborrhea 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 strabismus, exophthalmos or ptosis. Sclera white, conjunctiva 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 AV nicking, hemorrhages, exudates 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. Non-tender to palpation; continuity intact. 

Teeth – Good dentition and no obvious dental caries noted.

Gingivae – Pink; moist. No hyperplasia; masses; lesions; erythema or discharge. Non-tender to palpation.

Tongue – Pink; well papillated; no masses, lesions or deviation noted. Non-tender to palpation.

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.   FROM; no stridor noted. 2+ Carotid pulses, no thrills; bruits noted bilaterally, no palpable adenopathy noted.

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

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. No tenderness to palpation. 

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

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

Meningeal signs negative. No nuchal rigidity noted. Brudzinski and Kerning’s signs are negative.

Abdomen

Abdomen flat and symmetric with scar noted on right side, striae or pulsations noted. Bowel sounds slightly decreased with no aortic/renal/iliac or femoral bruits. Tender to palpation with more significant tenderness on the left side and tympanic throughout, slight guarding or rebound noted. No hepatosplenomegaly to palpation, 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. Carotid pulses are 2+ bilaterally without bruits.

Genitalia and Rectal

4 cm raised cyst examined in the superior midline gluteal cleft. Swelling, erythema noted surrounding the cyst. Tender to palpation.  Denied internal exam.

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.

Differential Diagnoses 

Assessment – ZS is a reliable 21-year-old Caucasian male who presents to the ED complaining of lower back pain that is most consistent with a recurrent pilonidal cyst.

Assessment:

1. Recurrent pilonidal cyst

Plan:

1. Drainage of the pilonidal cyst
2. Pain medication
3. Follow up at the colorectal surgeon for schedule of pilonidal cystectomy.
4. Education on the dressing changes of the site.