H&P 1

Name: HG
Age: 53
Ethnicity: Caucasian
Address: Hicksville
Location: Statcare hicksville
Source: Self
Reliability: Reliable 

Mode of transport: private vehicle 

 

History:
 

Chief complaint:  “I feel pressure and pain with urination for 4 days” 

HPI: 

HG is a 53 year old female with a past medical history of HTN and HLD who comes into the clinic complaining of pain and pressure sensation with urination for 4 days. She says her symptoms started when she was resting at home, and have been constant and worsening since yesterday. She describes it has a heavy pressure with urination, along with pain and increased frequency and urgency when she urinates. She says the pain is alleviated when she drinks more water and rest. She rates her discomfort as a 6/10 at its worst. She says she used Monistat 2 days ago with mild relief of symptoms. Patient denies any odor with her urine, blood in the urine, or any flank. She denies any history of kidney stones in the past. Patient has associated dysuria, increased frequency and urgency but denies any odor in the urine, abdominal pain, fevers, chills, or changes in bowel movements. She has had many similar episodes in the past.  

 

Past Medical History: 

• HTN: diagnosed 10 years ago 
• HLD: diagnosed 10 years ago 

Immunizations: 

• COVID vaccine 9/30/21 2nd dose Pfizer 
• All other vaccinations up to date 

Past surgical history:  

• C-section in 2002, no complications 

Medications: 

• Aspirin 85mg 
• Atorvastatin  

• Lisinopril 

Allergies: 

• Seasonal allergies 
• NKDA 

Family history: 

• Mother: deceased at age 80 secondary to MI 
• Father: alive and well 

Social history: 

• Patient lives at home with husband in a private home in Hicksville 
• Habits: Admits to drinking wine during the weekend, denies any use of cigarettes or illicit drugs.  

• Travel: denies recent travel or sick contacts 
• Diet: eats health chicken and vegetables  
• Exercise: walks 30 minutes a day 

 

Review of Systems: 

• General: denies fever, weakness, chills, or any recent weight gain or loss 
• Skin, Hair, Nails: Denies any rashes, lesions or discolorations  
• Head: Denies headache, vertigo, trauma, loss of consciousness or coma.   
• ENT: Denies ear pain, pressure or tinnitus, denies congestion or discharge, denies sore throat, swollen lymph nodes or neck pain 
• Nose/sinuses: Denies discharge, congestion or epistaxis 

• Pulmonary System: Denies shortness of breath, cough, wheezing, hemoptysis, cyanosis 
•  Cardiovascular System: Denies chest pain, palpitations, irregular heartbeat 
• Gastrointestinal System: Denies abdominal pain, diarrhea, constipation, nausea, vomiting 
• Genitourinary: Admits to dysuria, increased frequency and urgency.  
• Musculoskeletal System: Denies muscle/joint pain, deformity or swelling 

•  Hematologic System: denies anemia, easy bruising or bleeding, history of DVT/PE.   
• Endocrine System: Denies polydipsia, polyphagia, polyuria 
• Nervous System: Denies seizures, loss of consciousness, sensory disturbances  loss of strength or decrease in sensation 
• Psychiatric: Denies Anxiety or depression.  

 

Physical exam: 

• Vitals: BP: 134/87 (right arm sitting), Pulse: 87, Resp: 16 (unlabored), Temp: 98.7 (oral) , O2: 98% (on room air), BMI: 21.6kg/m2 
• General: patient is AxO x3, in no acute distress and looks stated age. 
• Skin: No jaundice, discoloration, lesions or rashes.  
• Head: Normocephalic, no tenderness. No lesions or bruises 

• Eyes: No jaundice, cornea clear, conjunctiva white. No ptosis. PERRLA, EOMI. Visual acuity exam denies. Visual fields full to confrontation OU.  
• Ears: No erythema or lesions. Whisper test unremarkable. Webber and Rinne unremarkable.  
• Nose: Nares patent, no discharge or congestion 
• Mouth/throat: Mucous membranes moist without any ulcerations. No erythema or tonsillar exudates. Uvula rises symmetrically. 
• Neck: Non-tender. Thyroid not enlarged and no lymphadenopathy. 

• Cardiac: RRR, no murmurs, rubs or gallops. No heaves or thrills noted. S1 and S2 heard.  
• Lungs: lungs are clear to auscultation bilaterally. No respiratory distress. Chest rise is symmetric.  
• Abdomen: Flat and symmetric, not distended. Soft with no tenderness to palpation. No guarding or rebound. No CVA tenderness.  
• GU: no suprapubic tenderness Musculoskeletal: grossly intact. GYN exam denied.  
• MSK: FROM of all extremities, no pain or weakness. +2 pulses throughout.  

• Neurological: no sensory or motor deficits  

 

Labs/testing: 

• Urinary analysis: 

• BLD: neg 

• UBG: neg 
• BIL: neg 
• PRO: neg 
• Nit: positive 
• Ketone: neg 

• Glu: neg 
• PH: 6.5 
• SG: 1.010 
• Bacteria: 500 

• Urine Culture sent out to lab: awaiting results 

Assessment: 

HG is a 53 year old female with a history of HTN and HLD who comes in complaining of pain and pressure with urination for 3 days. History and UA is consistent with a UTI.  

DDx:  

• Uncomplicated UTI 
• Pyelonephritis 

• Complicated UTI 
• Vaginitis 
• PID 

Plan: 

UTI: Macrobid 100mg q12hrs PO for 7 days.  

• Educate patient on increasing hydration. Also advise patient to urinate after intercourse. Patient advised to follow up if symptoms worsen or don’t resolve. Also advise patient to go to the ER in cases of heavy bleeding, high fever or any other abnormal symptoms.  

HTN: continue lisinopril 

HLD: continue atorvastatin 

 

 ==============================================================================================

H&P 2

Patient Identification: 

Name: TS
Age: 45
Ethnicity: Hispanic
Address: Queens
Location: Statcare hicksville
Source: Self
Reliability: Reliable 

Mode of transport: private vehicle 

 

History:
 

Chief complaint:  “I have a sore throat and congestion for 3 days”  

HPI: 

TS is a 45 year old female with no past medical history who comes in complaining of 3 days of sore throat and congestion. She states the pain started while she was home and says its been constant and worsening. The pain is worse with swallowing both liquids and solids. She describes the sore throat as a sharp stabbing sensation, and says her throat feels very inflamed and irritated. She says the pain is worsened with swallowing solids but is mildly alleviated with drinking hot teas. She rates it as a 7/10 at its worst. She had a negative Rapis COVID test done 2 days ago. She says that she had Strep throat as a kid a lot and this feels similar. She has associated fatigue, sore throat and congestion but denies any fever, cough, chills, ear pain, chest pain or shortness of breath. She is a teacher at a school and is unaware of any possible exposure.  

 

Past Medical History: 

• denies 

Immunizations: 

• COVID vaccine 4/22/21 2nd dose Pfizer 
• All other vaccinations up to date 

Past surgical history:  

• Skin tag removal in 2010, no complications 

Medications: 

• Multivitamin daily 

Allergies: 

• Seasonal allergies 

• NKDA 

Family history: 

• Mother: alive and well 
• Father: alive and well 

Social history: 

• Patient lives at home with husband in a private home in Queens 
• Habits: denies any use of alcohol,  cigarettes or illicit drugs.  
• Travel: denies recent travel or sick contacts 
• Diet: eats a vegetarian diet  
• Exercise: exercises 3 times a day 

 

Review of Systems: 

• General: admits fatigue, denies fever, weakness, chills, or any recent weight gain or loss 
• Skin, Hair, Nails: Denies any rashes, lesions or discolorations  
• Head: Denies headache, vertigo, trauma, loss of consciousness or coma.   

• ENT: Admits to sore throat and congestion, Denies ear pain, pressure or tinnitus, denies discharge, denies swollen lymph nodes or neck pain 
• Nose/sinuses: Admits to congestion, Denies discharge or epistaxis 
• Pulmonary System: Denies shortness of breath, cough, wheezing, hemoptysis, cyanosis 
•  Cardiovascular System: Denies chest pain, palpitations, irregular heartbeat 
• Gastrointestinal System: Denies abdominal pain, diarrhea, constipation, nausea, vomiting 

• Genitourinary: Denies dysuria, increased urgency or frequency.  Musculoskeletal System: Denies muscle/joint pain, deformity or swelling 
•  Hematologic System: denies anemia, easy bruising or bleeding, history of DVT/PE.   
• Endocrine System: Denies polydipsia, polyphagia, polyuria 
• Nervous System: Denies seizures, loss of consciousness, sensory disturbances  loss of strength or decrease in sensation 
• Psychiatric: Denies Anxiety or depression.  

 

Physical exam: 

• Vitals: BP: 128/84 (right arm sitting), Pulse: 76, Resp: 16 (unlabored), Temp: 98.7 (oral) , O2: 98% (on room air), BMI: 22.4kg/m2 
• General: patient is AxO x3, in no acute distress and looks stated age. 
• Skin: No jaundice, discoloration, lesions or rashes.  

• Head: Normocephalic, no tenderness. No lesions or bruises 
• Eyes: No jaundice, cornea clear, conjunctiva white. No ptosis. PERRLA, EOMI. Visual acuity exam denies. Visual fields full to confrontation OU.  
• Ears: No erythema or lesions. Whisper test unremarkable. Webber and Rinne unremarkable.  
• Nose: mildly congested bilaterally, Nares patent, no discharge 
• Mouth/throat: Erythema and edema to oropharynx and tonsils. Mucous membranes moist without any ulcerations. No tonsillar exudates. Uvula rises symmetrically. 

• Neck: Non-tender. Thyroid not enlarged and no lymphadenopathy. 
• Cardiac: RRR, no murmurs, rubs or gallops. No heaves or thrills noted. S1 and S2 heard.  
• Lungs: lungs are clear to auscultation bilaterally. No respiratory distress. Chest rise is symmetric.  
• Abdomen: Flat and symmetric, not distended. Soft with no tenderness to palpation. No guarding or rebound. No CVA tenderness.  
• GU: no suprapubic tenderness Musculoskeletal: grossly intact. GYN exam denied.  

• MSK: FROM of all extremities, no pain or weakness. +2 pulses throughout.  
• Neurological: no sensory or motor deficits  

 

Labs/testing: 

• Rapid Swab: positive 

• Rapid flu: negative 
• Rapid COVID: negative 
• Throat culture sent to lab 

 

Assessment: 

TS is a 45 year old female with no past medical history who comes in complaining of sore throat and congestion for 3 days. History, physical exam and rapid strep exam is consistent with Strep Throat.  

DDx:  

• Strep throat 
• COVID 19 
• Bronchitis 

• Laryngitis 
• Viral URI 

Plan: 

Strep Throat: Amoxicillin 500mg PO BID for 10 days.  

• Educate patient on increasing hydration and doing salt water gargles. Also instruct patient to drink hot teas to sooth the throat. Advise patient to not share anything with others such as spoons, straws, or kissing. Patient advised to follow up if symptoms worsen or don’t resolve. Also advise patient to go to the ER in cases of bleeding, high fever or any other abnormal symptoms.  

==============================================================================================

H&P 3

Patient Identification: 

Name: AS
Age: 22
Ethnicity: Asian
Address: Westbury
Location: Statcare hicksville
Source: Self
Reliability: Reliable 

Mode of transport: private vehicle 

 

History: 

Chief complaint:  “I have pain in my left year for 9 days” 

HPI: 

AS is a 22 year old male patient with a history of vertigo presents to the clinic complaining of left ear pain for 9 days. She says the pain started suddenly while she was at home, and is localized only to the left ear. The pain is constant and worsening, and he describes it has a sharp shooting sensation. Tylenol mildly alleviates the pain, and nothing makes it worse. Patient denies any recent swimming pool use or q tip use. He says that ear pain is also making him feel dizzy, and describes it as a room spinning sensation. He says he tried to use a alcohol and water solution to clear his ear with no relief. Patient denies any history of ear infections as a child. Patient has associated left ear pain and pressure sensation, dizziness, and headaches, but denies any congestion, cough, fever, chills or pain to the contralateral ear.  

 

Past Medical History: 

• Vertigo 

 

Immunizations: 

• COVID vaccine 3/19/21 2nd dose Pfizer 
• All other vaccinations up to date 

Past surgical history:  

• denies 

Medications: 

• Meclizine (PRN with vertigo symptoms) 

 

Allergies: 

• Seasonal allergies 
• NKDA 

Family history: 

• Mother: alive and well 

• Father: alive and well 

Social history: 

• Patient lives at in an apartment in Westbury with a roommate 
• Habits: Admits to occasional alcohol use, but denies smoking cigarettes or using any illicit drugs 
• Travel: denies recent travel or sick contacts 

• Diet: healthy diet with occasional fast food 
• Exercise: goes to the gym 4 times a week 

Review of Systems: 

• General: denies fatgiue, fever, weakness, chills, or any recent weight gain or loss 
• Skin, Hair, Nails: Denies any rashes, lesions or discolorations  

• Head: admits headache and dizziness, trauma, loss of consciousness or coma.   
• ENT: Admits to ear pressure and pain, denies congestion, and sore throat, swollen lymph nodes or neck pain 
• Nose/sinuses: denies congestion, Denies discharge or epistaxis 
• Pulmonary System: Denies shortness of breath, cough, wheezing, hemoptysis, cyanosis 
•  Cardiovascular System: Denies chest pain, palpitations, irregular heartbeat 

• Gastrointestinal System: Denies abdominal pain, diarrhea, constipation, nausea, vomiting 
• Genitourinary: Admits to dysuria, increased frequency and urgency.  
• Musculoskeletal System: Denies muscle/joint pain, deformity or swelling 
•  Hematologic System: denies anemia, easy bruising or bleeding, history of DVT/PE.   
• Endocrine System: Denies polydipsia, polyphagia, polyuria 

• Nervous System: Denies seizures, loss of consciousness, sensory disturbances loss of strength or decrease in sensation 
• Psychiatric: Denies Anxiety or depression.  

 

Physical exam: 

• Vitals: BP: 121/76 (right arm sitting), Pulse: 91, Resp: 16 (unlabored), Temp: 98.6 (oral) , O2: 98% (on room air), BMI: 17.22kg/m2 

• General: patient is AxO x3, in no acute distress and looks stated age. 
• Skin: No jaundice, discoloration, lesions or rashes.  
• Head: Normocephalic, no tenderness. No lesions or bruises 
• Eyes: No jaundice, cornea clear, conjunctiva white. No ptosis. PERRLA, EOMI. Visual acuity exam denies. Visual fields full to confrontation OU.  
• Ears: left ear: tympanic membrane erythema, dullness and absent light of reflection. Mild Bilateral cerumen impaction. Right ear: unremarkable. Cone of light visible, no fluid build up. Whisper test unremarkable. Webber and Rinne unremarkable.  

• Nose: Nares patent, no discharge or congestion 
• Mouth/throat: Mucous membranes moist without any ulcerations. No erythema or edema to oropharynx or tonsils. No tonsillar exudates and uvula rises symmetrically. 
• Neck: Non-tender. Thyroid not enlarged and no lymphadenopathy. 
• Cardiac: RRR, no murmurs, rubs or gallops. No heaves or thrills noted. S1 and S2 heard.  
• Lungs: lungs are clear to auscultation bilaterally. No respiratory distress. Chest rise is symmetric.  

• Abdomen: Flat and symmetric, not distended. Soft with no tenderness to palpation. No guarding or rebound. No CVA tenderness.  
• GU: no suprapubic tenderness Musculoskeletal: grossly intact.  
• MSK: FROM of all extremities, no pain or weakness. +2 pulses throughout.  
• Neurological: no sensory or motor deficits  

 

Assessment: 

AS is a 22 year old male with a past medical history of vertigo who comes in complaining of left ear pain for 9 days. History and physical exam is consistent with otitis media.  

DDx:  

• Otitis media 
• Otitis externa 

• Vertigo 
• Cerumen impaction 
• Viral illness 

 

Plan: 

Otitis media: Augmentin 875mg 1 tablet PO q12 hours for 10 days.  

• Educated patient on avoiding swimming pools or baths, and to keep the ear dry. Patient instructed to go to the ER in cases of heavy bleeding, high fever or any other abnormal symptoms.  

Vertigo: continue meclizine as needed and follow up with PCP.