HISTORY

Identifying Data

Name: Y.C.

DOB: 10/01/1950

Date and Time: 02/22/2022 at 8:30 AM

Location: NYPQ

Religion: Jewish

Source of Information: Self

Reliability: Reliable

Mode of Transport: Ambulance

CC

“I had a 104-degree fever and wasn’t able to urinate” x 3 days

HPI

71 YO male with PMH of uric acid stones, gouty arthritis, BPH, and DVT/PE was admitted to Internal Medicine 3 weeks ago after presenting with high fever and urinary retention for 3 days. States that fever developed acutely on a Thursday, which then lowered to 101 degrees before being brought in that Saturday. Before this acute episode, complained of increased urinary frequency, nocturia, increased urinary urgency, dysuria (sharp pain at the tip of the penis), awakening at night to urinate, and nighttime incontinence. Urine clear and yellow. Last prostate exam 4 years ago – hypertrophy of the median lobe. Denies flank pain.

PMH

Bladder stones, 15 years ago

Bladder stones, 4 years ago

DVT/PE, a few years ago

Genetic clotting disorder, tx’d medically

BPH x 4 years, not taking meds

Gouty arthritis in both knees, 2 months ago

Denied any major childhood illnesses

Up to date w/ immunizations + 2 doses COVID

Last colonoscopy 10 years ago – one polyp removed

Prostate exam 4 years ago – neg. for cancer

PSH

Bladder stones broken up w/ high pressure water jet, Northwell hospital, 15 years ago

Bladder stones removed w/ laser therapy, 4 years ago

Left percutaneous nephrostomy tube placed, NYPQ, 3 weeks ago

Received 3 blood transfusions w/in past 3 weeks due to low Hgb – cause unknown           

Denies hx of eye surgery, gallbladder surgery, or hernia repair.

Meds

warfarin 2 mg daily; 4 mg weekly for DVT prophylaxis, not compliant with INR checks

Denies taking any other medication.

Allergies

Denies any drug, environmental, or food allergies.

Family Hx

Father – deceased, 75, prostate cancer

Mother – deceased, 48, blood clot secondary to surgery (hysterectomy)

Daughter #1 – alive, 32, recurrent syncope and low BP

Daughter #2 – 35, healthy

Son – 40, healthy

States an uncle and aunt both died from colon cancer.

Denies family hx of diabetes or CV disease.

Social Hx

Y.C. is in his second marriage of ten years and lives with his wife. He works from home and volunteers once a week, delivering food. States his frequent urination means he has to use recipients’ bathrooms frequently.

Habits – He drinks a glass of wine twice a week during his book journal meeting. Denies past and present tobacco use. Denies history of illicit drug use. He does not drink caffeine but occasionally has a cup of tea.

Travel – Recently traveled to California last month to visit his best friend.

Diet – He has a daily vegan diet, in addition to a well-balanced diet with fruits and vegetables.

He tries to minimize his salt intake.

Exercise – He walks about 1 mile a day in his neighborhood.

Sleep – Does not get a good night’s rest due to nocturia.

Safety measures – Admits to wearing a seat belt.

Sexual Hx – Heterosexual, monogamous. Does not use barrier protection. Denies hx of STIs.

ROS

General – Fever has resolved. Denies any change in appetite, recent weight loss or gain, generalized weakness/fatigue.

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 visual disturbances, lacrimation, pruritis, or photophobia. He does not wear glasses. Last eye exam 2012. Does not know his visual acuity; normal pressure.

Ears – Denies deafness, pain, discharge, tinnitus or use of hearing aids.

Nose/sinuses – Denies discharge, obstruction or epistaxis.

Mouth/throat – Denies bleeding gums, sore tongue, sore throat, mouth ulcers, voice changes or use of dentures. Last dental exam in 2011, no significant findings.

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 – States he has irregular heartbeat. Denies palpitations. Denies chest pain, HTN, edema, syncope, known heart murmurs.

Gastrointestinal system – Admits to unrelenting eructations x 1 year, no known cause. Denies change in appetite, intolerance to specific foods, pyrosis, flatulence, abdominal pain, diarrhea, change in bowel habits, hemorrhoids, constipation, blood in stool. Last colonoscopy 10 years ago, see PMH.

Genitourinary system – See HPI.

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

Musculoskeletal system – Denies muscle/joint pain, 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 – Admits to history of DVT/PE. Received 3 transfusions past 3 weeks.  Denies anemia, easy bruising or bleeding, lymph node enlargement.

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

Head: Balding, fine hair. Normocephalic, atraumatic.

Skin: 16 cm x 4 cm flat, reddish-brown rash noted on right lower leg. Dry, cracked skin on feet.

Nails: Smooth, no pitting.