Identifying Data:

Full Name: JS

Sex: M

Address: Manhasset, NY  

Age: 66 Y/O 

Date & Time: 05/31/21

Location: NSUH

Religion: Denies

Marital Status: Married

Race: Caucasian  

Nationality: American

Source of Information: Self

Reliability: Reliable

Mode of Transport: Self

Chief Complaint: “I have a headache” x6 hours  

History of Present Illness:

JS is a 66 year old reliable Caucasian male, with a  history of HTN that presents with persistent L sided squeezing HA. It began while he was sitting on the couch and watching TV around 2 pm. He took 2 tabs of Tylenol but experienced no relief. The pain is progressively worse, 4/10 – 8/10. It is described as a constant and band-like pain. JS admits to a “left chest cramp” that was associated with the headache, that was rated a 5/10, but states that it resolved before her arrival to the hospital. Throughout the past week she has had palpitations with exertion.

JS denies any visual changes, weakness, photophobia or tinnitus.  JS also denies diplopia, photophobia, lacrimation, or hearing difficulties (bilaterally). Patient also denies chest pain, shortness of breath, nausea, vomiting and diaphoresis. JS has not come in contact with anyone who is sick and has not traveled anywhere recently.

Past Medical History:

Present medical illnesses – Denies.

Childhood illnesses – Denies.

Immunizations – Up to date. 

Past Surgical History:

Denies.

Medications:

Losartan-hydrochlorothiazide 100 mg-25 mg, PO, once daily

Allergies:

Denies environmental, medication and food allergies.

Family History:

Mother – 78, deceased due to unknown causes

Father – 54, deceased due to unknown causes

Denies family history of cancer, diabetes and cardiovascular disease

Social History:

JS is a married man, that lives with his cousin. He works as an access-a-ride driver. He is active every day, 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. He has not traveled anywhere recently

Review of Systems:

General – Admits to headache. Denies fever, loss of appetite, recent weight gain or loss, generalized weakness/fatigue, 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 – Admits to headache. Denies dizziness, vertigo or head trauma, head fracture or coma.

Eyes –Denies contacts or glasses, visual disturbances, fatigue, photophobia, and pruritus. Last eye exam x2 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–Admits to left retrosternal chest cramp. Admits to palpitations with exertion. Denies swelling of the extremities, irregular heartbeat, syncope or known heart murmur.

Gastrointestinal-  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 wife. 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 – Denies deformity or swelling, redness or arthritis. Denies joint or muscle pain.

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             118/76                                                  120/76

Supine             124/78                                                 120/76

R:         18 breaths/min unlabored                 P: 85 beats/min regular

T:         98 degrees F (temporal)                     O2 Sat: 99% 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 – 20/30 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

No ecchymosis, edema, erythema, bleeding, discharge or deformities. Non-tender. 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. No striae or pulsations noted. Bowel sounds slightly decreased with no aortic/renal/iliac or femoral bruits. Nontender. 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

Denied 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.

Labs

CMP

Glucose serum – 109

Magnesium – 2.2

CBC – All within normal limits

COVID PCR – Negative

Radiology

CT Head – No acute intracranial hemorrhage, large cortical infarct or mass effect. If clinically indicated can follow up with MRI.

X-ray of Chest AP or PA – Clear lungs. No pleural effusion or pneumothorax. Degenerative changes of the spine.

EKG – Frequent PVCs and changes in the inferior leads. Otherwise normal

Differential Diagnosis

1. MI
2. Intracranial hemorrhage
3. CVA
4. Migraine, tension Headache
5. Angina

Assessment – JS is a 66 year old reliable Caucasian male, with a  history of HTN that presents with persistent progressive headache and left chest “cramp” that has been admitted for ischemic evaluation.

Plan:

1. Acute non-intractable headache
   1. Given Tylenol 975 mg in the ED, now HA has resolved
      1. CTH w/o ICH, mass or CVA
2. Chest pain
   1. Will monitor on tele and serial cardiac enzymes
   1. ASA 324 mg in the ED, ASA 81 for now
   1. Will check TTE to evaluate for structural heart disease
   1. Ischemic eval with cardiac CT vs. Stress test
3. Essential HTN
   1. Continue losartan/HCTZ
4. Prophylactic measures
   1. Lovenox SC