Full Name: Ms. L
Age: 33 y/o
Reliability: Reliable
Location: New York Presbyterian Queens
Source of information: Patient herself
Chief Complaint: “I am here for surgery”
History of Present Illness:
33y/o female presents with a PMH of morbid obesity, lupus, sleep apnea, asthma, fibromyalgia, and arthritis, pt. has tried changes in exercise, diet, and other lifestyle modifications but has seen no improvements therefore she is being seen today for preoperative workup for a robotic assisted sleeve gastrectomy. Pt. presents with no current complaints and no pertinent positives. Pt. denies any changes in bowel movements, changes in appetite, nausea, vomiting, abdominal pain, constipation, dyspnea, diarrhea, blood in stool, urinary frequency, nocturia, weakness, and fever.
Past Medical History:
- Asthma x 10 years controlled medically
- Lupus x 6 years controlled medically
- Arthritis x 6 years controlled medically
- Fibromyalgia x 5 years controlled medically
- Depression x 4 years controlled medically
- Sleep apnea x 7 years controlled medically
- Migraine x 5 years controlled medically
Past Surgical History:
- Left nephrectomy 2009, no complications
Medications:
- Gabapentin 400 mg QHS, most recent dose last night
- Zoloft 150 mg QD, most recent dose this am
- Hydroxychloroquine 200 mg BID, most recent dose this am
- Aimovig once a month subcutaneous injection, most recent dose Jan 25th
- Symbicort BID, most recent dose this am
Allergies:
- NKDA
- Denies seasonal, food, or animal allergies
Family History:
Mother – age 67 alive and well
Father- age 78 with h/o of diabetes and hypertension
Paternal grandmother- unknown health history deceased at 93 y/o
Paternal grandfather- unknown health history deceased at 87 y/o
Maternal grandmother- unknown health history deceased at 89 y/o
Maternal grandfather- unknown health history unknown age of death
Social History:
- Reports h/o smoking hookah for 8 years and quit last year
- Reports two cups of coffee a day
- Reports she drinks alcohol on weekend estimated 3 cocktails every weekend
- Denies h/o illicit drug use
- Travel: no recent travel
- Diet: pt. states she has been improving her diet by cutting back on carbs and staying away from “fatty and sugary foods”
- Exercise: Pt. reports she has been attempting to exercise twice a week
- Sexual Hx: heterosexual, pt. states she has not been sexually active for the past 4 years. Denies h/o any sexually transmitted disease.
Review of Systems:
General – Denies recent weight loss or gain, loss of appetite, generalized weakness/fatigue, fever or chills, 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 headaches, vertigo, or head trauma.
Eyes –Denies any visual disturbances, or photophobia, lacrimation, pruritis.
Ears – Denies deafness, pain, discharge, tinnitus.
Nose/sinuses – Denies discharge, obstruction, or epistaxis.
Mouth/throat – Denies bleeding gums, sore tongue, sore throat, mouth ulcers, or voice changes.
Neck – Denies localized swelling/lumps or stiffness/decreased range of motion Breast – Denies lumps, nipple discharge, or pain.
Pulmonary system – Denies dyspnea, dyspnea on exertion, cough, wheezing, hemoptysis, cyanosis, orthopnea, or paroxysmal nocturnal dyspnea (PND).
Cardiovascular system –Denies chest pain, irregular heartbeat, edema/swelling of ankles or feet, syncope or known heart murmur, palpitations
Gastrointestinal system – see HPI
Genitourinary system – Denies urinary frequency or urgency, nocturia, oliguria, polyuria, dysuria, incontinence, awakening at night to urinate or flank pain.
Menstrual/Obstetrical- LMP February 16th, 2022. Denies breakthrough bleeding/spotting or vaginal discharge.
Nervous – Pt. has h/o chronic migraine but denies current migraine in office. Denies seizures, loss of consciousness, sensory disturbances, ataxia, loss of strength, change in cognition / mental status / memory, or weakness.
Musculoskeletal system – Pt. has h/o of arthritis, lupus, and fibromyalgia but denies muscle/joint pain, deformity or swelling, or redness in office.
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, lymph node enlargement, blood transfusions, 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.
Physical:
General: Heavy set female, neatly groomed, appears to be in no distress.
Skin: warm & moist, good turgor. Nonicteric, no lesions noted, no scars. Tattoo located on right wrist approx. 6 inches.
Hair: average quantity and distribution.
Nails: no clubbing, capillary refill <2 seconds throughout.
Head: normocephalic, atraumatic, non-tender to palpation throughout.
