Presenting Problem and History of the Present Illness
18 y/o female patient who denies significant PMH who is presenting to Federal Qualified Health Center (FQHC) for follow up on Rt wrist injury x 4 weeks. Patient had been seen by another provider 4 wks ago for right wrist pain. Documented etiology was not stated in previous clinic note. Patient was referred to PT & OT for therapy on wrist. X-ray done at previous visit was negative.
Pt. presents in office today with father. Wrist pain has persisted, with minimal improvement from therapy. Chart notation from OT & PT – concerns with progress, mechanism of injury not correlating with patient’s symptoms and c/o pain. Patient reports that nothing makes the pain better and movement makes the pain worse. The patient states that it is a dull ache that does not radiate. The patient rates it a 5/10 pain. The patient says the pain has been constant for the past month. The patient states that they have experienced other muscular injuries but they healed on their own. The patient feels that this injury is not getting better.
Past Medical History: Food dysphoria and dysphagia – diagnosed 2 years ago (thought to be related to parent’s separation) Did have referral to Speech and Language Pathologist, only attended one visit. Various musculoskeletal injuries documented over past 3 years. Asthma
Health maintenance: UTD on immunizations. Last well child visit (WCV) 3 years ago.
Referrals: Nutrition- 2 years ago. Did not keep follow up appointments (per chart notation). Behavioral health/Social work – 2 years ago. Inconsistent follow up, often missed appointments when staying at mom’s residence (chart notation, mom verbalized transportation issues).
Past OBGYN History: Denies prior gyn history
Past Surgical History: Denies surgeries
Past Psychiatric History: Denies past psychiatry history
Medications: Estradiol 2mg po bid x 6 months; Spironolactone 100 mg po bid x 6 months; Ventolin inhaler prn; Ibuprofen prn
Allergies: NKDA, NKFA, no environmental or latex allergies
Family Medical History: mother with ovarian cysts, maternal grandmother with breast cancer; all alive and otherwise healthy
Sexual History: Denies sexual activity; attracted to men; identities as straight
Review of Systems
General: Weight is sometimes “lower than normal” with a reported 6 lb. weight loss in past 6 months, appetite is low, sleep at night: restless (wakes up around 3am and has trouble going back to sleep sometimes), Denies fever, chills. + for malaise/generalized fatigue
HEENT: Denies visual disturbances, denies hearing changes or disturbances, denies balance problems, mild sore throat intermittently, Mild dysphagia (reports globus sensation of food stuck in throat), mild nasal congestion, denies sinus pressure
Cardiovascular: Denies chest pain, palpations, dyspnea on exertion, syncope or lightheadedness
Respiratory: Denies cough, or dyspnea when sitting or with exertion, admits wheezing, shortness of breath, cough at night (2 episodes per week which resolve spontaneously with rest)
Gastrointestinal: Denies heartburn, nausea, vomiting or constipation. Denies change in bowel habits, denies changes in stool quality or color, denies blood or mucous in stool, denies flatulence, denies bloating.
Genitourinary: Denies dysuria, hematuria, frequency or urgency or flank pain
Endocrine: Denies cold/heat intolerance, hair loss, dry skin, denies excessive thirst, denies skin changes
Musculoskeletal: Positive for right wrist pain, denies bruising, swelling, deformities elsewhere, denies gait disturbances or weakness. Denies left wrist pain.
Neurological: Denies alteration in sensation or motor function, Denies headaches and dizziness
Psychiatric: Positive for low mood, positive for mild anxiety, positive for sleep changes
Blood Pressure: 100/60 manual cuff
Respiratory Rate: 14
Heart rate: 99
Weight: 109 lbs
General: Alert and oriented to person and place and time, in no distress
Psych: Appearing shy, reserved; Eye contact is minimal, androgynously dressed, with heavy make-up and lipstick
HEENT: Scalp free of lesions, TMs WNL, ocular motility normal, no nystagmus, PERRL, Teeth and gingiva appear healthy/no evidence for caries, tongue normal, uvula midlines, oropharynx is non-erythematous, neck is supple with FROM, no thyromegaly or carotid bruit
Lymph: No axillary, cervical, epitrochlear, inguinal or femoral adenopathy
Breast: Declines exam, unable to assess Tanner stage
Lungs clear to percussion and auscultation bilaterally; Percussion - resonance; Auscultation - reduced breath sound, rhonchi, vesicular breath sound with prolonged expiration time
Cardiac: Regular rhythm without murmurs, gallops, rubs, PMI is in the 5th intercostal space, no JVD
Abdomen: Flat, soft, without tenderness in all quadrants with palpation, decreased but present bowel sounds.
GU: No CVA tenderness, no lower abdominal pressure or or lower pelvic pain
Gyn/Pelvic/Rectal: Refuses, unable to assess Tanner stage
Neurologic: Gait and speech are normal, no tremor, CN I, II through XII normal, strength is full in upper and lower extremities, noted pain with movement of the right wrist with pronation and supination, sensation is WNL, Reflexes symmetrical and brisk in the UE and LE
Extremities: No bruising, deformities or swelling noted, no muscle wasting, no venous abnormalities, pulses are full and symmetrical, right wrist pain and limited ROM with flexion, extension, ulnar and radial deviation, grip strength 3/5. No bruising, deformity or swelling noted on right wrist. No TTP over snuffbox, no point tenderness over distal radius or ulnar bones. Left wrist intact with FROM.
Skin: Intact skin, no freckles, no tattoos
Imaging wrist and forearm: Pending