Toor Noori   

Evaluator Visit H&P

 

Overall well done and well structured.  You are about where you should be for this point in your clinical year.  Please note the comments for areas that could still be improved.

 

History

 

Identifying Data:

Full Name: Mr. C

Address: Jamaica, NY

Age: 67

Date & Time: Would like to know date seen

Location: Urology clinic at Saint Albans long term care facility

Religion: Christian

Nationality: African American

Source of Information: self

Source of Referral: Self

 

Chief Complaint:  I have been going to the bathroom too much at night x 1 month.

 

HPI:

Mr C.  is a 67 y/o AA male 30 pack year former smoker (quit 15 years ago) w/ a PMHx of obstructive sleep disorder, HTN, GERD, erectile dysfunction, HLD, prostate cancer s/p radiation in 2015. He presents to the VA urology clinic today complaining of frequent night time urination x 1 month. Patient states he has been getting up to urinate 2-3 times during the night and it is interfering with his sleep. He denies any abdominal pain, fever, chills, dysuria, hematuria, dribbling, hesitancy, or change in color of urine. He drinks about 4-5 (8oz) glasses of water a day. Patient denies any alcohol use and drinks only 2 cups of coffee in the morning. He explains he takes some of his medications with about 1 (6oz) cup of water an ½ hour before bed. The medications he takes at night are nifedipine, and atorvastatin. He explains he has been taking these medications the same way for years and it has never been an issue before. He started using a CPAP machine for 2-3 hours a night 3-4 time a week for his sleep apnea x 1 week. He states before using the CPAP he would wake up tired and was fatigued throughout the day. However, he thinks using the machine has helped him feel less fatigue and more energized during the day.

 

Past Medical History:

Prostate cancer s/p radiation 2015 (intermediate risk (PSA 8.9) treated with 6 months Eligard hormonal therapy starting on 9/20/2016)

HTN x 5 years well controlled with medications

HLD x 8 years

Obstructive sleep disorder- x 1 year just started using CPAP machine for 2-3 hours a night 3-4 times a week (resulting in feeling less fatigue during the day)

GERD x 5 years – taking omeprazole 40 mg daily  (with max relief  med and diet/lifestyle modifications -use to feel nauseated and vomit every other day been almost symptom free for the past few months)

Erectile dysfunction x 2 years (uses Viagra and Alprostadil prn with no side effects reported)

 

Hospitalized- sleep study 11/5/2018, denies any other hospitalizations

Childhood illnesses – Chicken pox (he’s not very sure)

 

Immunizations – up to date on all vaccines including shingles, pneumococcal, and influenza.

Screening tests – last colonoscopy done 5/10/2018 ( with no abnormal findings)

depression screening- 01/07/2019 score 0

DM screening last – 01/07/2019 A1C= 5.3

PSA last done on 1/19/2019   level= .13

 

Past Surgical History:

Denies any surgical history

 

Medications:

Alprostadil 500 mg PRN suppository – ED

Sildenafil (Viagra) 100 mg 1 tab a day PRN- ED

Aspirin 81 mg chewable – preventative care

Atenolol 100mg tab once a day – HTN

Atorvastatin 40 mg one tab at bedtime- HLD

Nifedipine 30 mg two tablets in the evening — HTN

Loratadine 10 mg one tab a day PRN– allergies

Omeprazole 20 mg take two tab in the morning — GERD

 

Allergies:   seasonal allergies

Denies any drug or food allergies.

 

Family History:

Paternal Grandfather –  died in car accident at age 55

Paternal Grandmother – deceased unknown cause 70

Maternal Grandfather – died unknown cause 81

Maternal Grandmother – does not recall

Father –  deceased unknown cause age 75

Mother –   hx of HTN, DM, alive and well age 88

Sister: 60 alive and well

Son-  36 alive and well

daughter- 34 alive and well

 

Pt denies family h/o heart disease, respiratory disease, CVD,  allergies,  gastrointestinal disease, or psychiatric disorders.

 

Social Hx:

Travel – denies any recent long distance travel except for going to LA for a car show a few months ago.

Safety measures – admits to wearing a seat belt.

Former smoker ( 30 pack years stopped smoking 15  years ago)

No ETOH use

Denies any exposure to harmful chemical/substances such as agent orange, asbestos, or silicates.

Living condition: lives at home with wife and dog.

Married – sexually active ( uses viagra and Alprostadil PRN for Erectile dysfunction)

Diet: 2gram sodium and cholesterol restricted diet. Drinks two cups of coffee in the morning and has a bowl of oatmeal with fresh fruits. Avoids spicy/fried foods, and carbonated drinks. Meals consist of chicken/fish and salad for lunch or dinner sometimes has baked potatoes. Eats out on the weekend at his favorite deli in Bellmore.

Exercise: Patient likes to take walks with his wife and dog  in the morning x 7 days a week. Walks about 1 mile every time.

Hobbies: He like to work on his two cars Volvo, and Mustang during the week and take them to Bellmore on the weekends where crowds come out to look at unique cars. He takes his wife along and meets up with friends who bring their cars as well..

 

ROS:

General –  Denies fever, recent weight loss or gain, loss of appetite, generalized weakness/fatigue, chills, or night sweats.

 

Skin, hair and nails – denies change in texture, excessive dryness or sweating, discolorations, pigmentations, moles/rashes, pruritus, changes in hair distribution.

 

Head – Pt ℅ H/A x 3 days,  no vertigo or head trauma. Need more about the headache – (OLD CARTS  type information) probably unrelated, but too early to tell

 

Eyes – Denies problems with vision, visual disturbance, lacrimation, photophobia, pruritus.

Ears – Pt. denies any discharge, tinnitus, deafness or use of hearing aids.

 

Nose/Sinuses – Pt denies discharge , nasal congestion, sinus pressure,  epistaxis or obstruction.

 

Mouth and throat – Denies bleeding gums, sore throat or tongue, mouth ulcers, or voice changes. Last dental exam was 2 months ago.

 

Neck – denies localized swelling/lumps, stiffness/decreased range of motion.

 

Breast – denies lumps or pain.

 

Pulmonary System – hx obstructive sleep apnea. denies SOB, DOE,  wheezing, hemoptysis, cyanosis, orthopnea or PND.

 

Cardiovascular System – H/O HTN x 5 years, HDL x 8 years,  denies chest pain, palpitations, irregular heartbeat, syncope or known heart murmur.

 

Gastrointestinal System – Hx of GERD x 5 years avoids fried food, spicy foods, and carbonated drinks since they cause worsening of his GERD. He denies change in appetite,nausea /vomiting, dysphagia, pyrosis, flatulence, eructations, diarrhea, change in bowel habit, hemorrhoids, or melena.

 

Genitourinary System –   hx of prostate cancer s/p radiation therapy,  ℅  frequent nighttime urination  x 1 month,denies flank pain, dribbling, oliguria, polyuria, dysuria, incontinence, blood in the urine, or hesitancy. Would like to note specifically whether he has any increased frequency during the day or any urgency.

 

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

 

Musculoskeletal System – no pain, deformity/swelling, redness, or arthritis.

 

Peripheral Vascular System – Denies any peripheral edema. denies intermittent claudication, coldness or trophic changes, varicose veins, color change.

 

Hematologic System –; denies blood transfusions, anemia, easy bruising or bleeding, lymph node enlargement, or history of DVT/PE.

 

Endocrine System – denies polyuria/polydipsia/polyphagia, heat or cold intolerance, goiter, excessive sweating, hirsutism.

 

Psychiatric -denies any depression/sadness, anxiety, denies obsessive/compulsive disorder, seeing a mental health professional, taking psychiatric medications.

 

Physical

 

General: 67 y/o AA male , AO x3 appears to be in no apparent distress. Patient is well developed, and well groomed, and looks older than his stated age.

 

Vital Signs:

BP: Seated   128/72,

RR: 18 breaths/min, unlabored

HR: 74 beats/min, regular

Temp: 97.3 T (oral)

O2 Sat: 97%, room air

Height:  5.11”

Weight:  176 lbs

BMI: 24.5

Labs: UA complete (pending)

Last PSA .13 done on 01/19/2019

Last A1c  5.3 done on 01/07/2019

 

Physical Exam:

Skin:  warm & moist, good turgor. Nonicteric, no lesions/scars noted, small tattoo noted on upper left arm.

Hair: average quantity and distribution.

Nails: no clubbing, capillary refill <2 seconds throughout.

Head: normocephalic, atraumatic, non-tender to palpation throughout.

Eyes: symmetrical OU; no evidence of strabismus, exophthalmos or ptosis; sclera white; conjunctiva & cornea clear.

Visual fields full OU. PERRLA, EOMs full with no nystagmus. Visual acuity test not performed.

Ears: Symmetrical and normal size. No evidence of lesions/masses/trauma on external ears.

no discharge/foreign bodies. TM’s clear w/normal cone of light, erythema, or exudates. Auditory acuity intact to whispered voice AU.

 

Nose:  No erythema, no swollen turbinates, nose symmetrical, no obvious masses. or evidence of foreign bodies.

Oropharynx: no erythema; well hydrated; no evidence of exudate; masses; lesions; foreign bodies. Tonsils present with no evidence of injection or exudate. Uvula pink and midline, 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.

 

Chest – Symmetrical, no deformities, no evidence trauma. respirations are unlabored. no use of accessory muscles noted. Lat to AP diameter 2:1. Non-tender to palpation.

 

Lungs – Lung fields clear to auscultation. No rhonchi or wheezing noted. No dyspnea on exertion.

 

Heart: .  normal S1 and S2 , no murmurs or extra heart sounds.

 

Abdominal-  Flat / symmetrical / no evidence of scars, striae, caput medusae or abnormal pulsations.

BS present in all 4 quadrants. No bruits noted over aortic/renal/iliac/femoral arteries.

Tympany to percussion throughout. non tender to  palpation, no rebound tenderness. No evidence of organomegaly. No masses noted. No guarding.

 

Extremities : Upper / lower extr : FROM, 5/5 muscle strength b/l, radial pulses 2+ b/l.

 

Pelvic: non palpable bladder, no pain on palpation over suprapubic region no sign of urinary retention. In a slender patient, percussion for suprapubic dullness is sometimes helpful.

 

Genitalia: no phimosis, scars, masses, or urethral discharge.

 

Rectal exam: no external  hemorrhoids or fissures noted,  Prostate: smooth, symmetrical and not enlarged, no nodules/masses noted.

 

Assessment: Mr C.  is a 67 y/o AA former smoker with hx of 30 pack years. He has a PMHx of obstructive sleep disorder, HTN, GERD, erectile dysfunction, HLD, Prostate cancer s/p radiation 2015 ℅ frequent night time urination x one month. His vital signs are stable and physical exam is unremarkable. He denies drinking alcohol but drinks 2 cups of coffee every morning,  and takes a calcium channel blocker Nifedipine for HTN at bed time. He has a PMHx of OSA (recently started using CPAP), and prostate cancer s/p radiation, PSA is followed every 6 months his last PSA recorded at .13.

 

 

Plan:

 

Frequent Urination: Needs mention of the U/A and follow up of results – this could all be due to a UTI

 

Keep a bladder diary (Pt prefers paper diary does not like to use the APP)

Provide patient with all materials needed ( paper diary, urine collection device)

Educate patient on how to use the diary, the importance of keeping a diary, to keep diary for 3-4 days, and bring back on next appt.

 

Educate the patient on the

 

-role of coffee, Nifedipine, and OSA in nocturia.

-Minimising fluid intake at least 2 h before going to bed, particularly caffeine and/or alcohol

-Restricting total fluid consumption to <2 L/day

-Emptying bladder before going to bed

 

Discuss changes that can be made during future visits (after reviewing the bladder diary) when we have a better understanding of his symptoms. Changes that can be made to help improve symptoms include:

 

-Decreasing coffee intake

-changing medication time of Nifedipine from evening to morning

-increase hours/days of CPAP use

 

Also discuss the possibility of prescribing medication (new drug approved by FDA desmopressin a vasopressin analog) for symptoms if life style modification do not help decrease symptoms.

 

Make f/u appt with urology in 1 week

 

HTN Needs the assessment part – e.g. “well controlled on current meds and diet”

diet 2gram sodium

Continue meds Atenolol 100mg tab once a day and

Nifedipine 30 mg two tablets in the evening

Continue to f/u with PCP

 

HLD Needs the assessment part

cholesterol restricted diet

continue to take: Atorvastatin 40 mg one tab at bedtime

Continue to engage in physical activity as tolerated

f/u with PCP

 

Erectile Dysfunction Needs the assessment part – here it would be something about how satisfied the patient is with his current regimen and whether there are any sexual function issues

Continue to take

Alprostadil 500 mg PRN suppository

Sildenafil (Viagra) 100 mg 1 tab a day PRN- ED

 

Seasonal allergies

Continue to take Loratadine 10 mg one tab a day PRN

 

GERD Needs the assessment part

Continue to take Omeprazole 20 mg take two tabs in the morning

Continue to avoid spicy/fried foods, and carbonated drinks.

Continue to f/u with PCP

 

Obstructive sleep disorder Needs the assessment part

Educate patient on the importance of using his CPAP machine as prescribed

continue to use CPAP as prescribed by pulmonologist

Continue to f/u with PCP and pulmonologist

 

Prostate cancer Needs the assessment part – here it would be something about no evidence for recurrence, citing the PSA and exam (though be aware that there are strictures and other issues that could be absent of findings on exam, but still relevant)

Continue to f/u with urology as recommended.

Schedule appt with urology for repeat PSA blood work on 7/19/2019