IDENTIFICATION: July 8, 2019
CG, F, Hispanic, 60 years old, widowed, 4123 Elliot St, Ridgewood, NY 12184, Catholic.

INFORMANT: Patient herself is a reliable historian.

REFERRAL SOURCE: Self

CHIEF COMPLAINT: ‘Leg pain’ x 8 months

PRESENT ILLNESS: 60 year old female, with a PMH significant for HTN, fibromyalgia, lupus, Reynaud’s disease and carpal tunnel syndrome, presents complaining of an 8 month history of pain behind her left knee. Patient reports she saw her PMD regarding this pain, who informed her it was likely due to her other comorbidities, but presents today asking for a second opinion. Patient denies taking any medications to help alleviate the symptoms. Denies blunt trauma or injury, radiation of pain down her leg, fall, inflammation, bruising.

Of note, patient was seen in this office two days ago complaining of blood in her stool and presents reporting two episodes of BRBPR today. Denies headache, lightheadedness, dizziness, fever, vomiting, constipation, chest pain, shortness of breath, rectal pain or history of hemorrhoids or fissures. Patient has an abdominal CT scheduled in two days, as per referral written at last visit.

PAST MEDICAL HISTORY

• HTN
• Fibromyalgia
• Lupus
• Reynaud’s Disease
• Carpal Tunnel Syndrome

PAST SURGICAL HISTORY

• N/A

MEDICATIONS

• Amlodipine Besylate, 10mg PO qd
• Hydrochlorothiazide, 25mg PO qd
• Dextroamphetamine Sulfate, 10mg PO qd

ALLERGIES

• NKDA
• No food/environmental allergies

FAMILY HISTORY

• Mother, 91, deceased, breast cancer
• Father, 89, alive, BPH, HTN.
• Sister, 64, alive, HTN.
• Sister, 62, alive, HTN.
• 3 Children, alive and well.

SOCIAL HISTORY

• Patient reports social EtOH, former smoker (30 pack years) denies any illicit drug use. Patient is widowed and lives with her daughter and her daughter’s family.

REVIEW OF SYSTEMS
General: Denies generalized weakness / fatigue, recent weight loss, change in appetite, fevers and night sweats.
Skin, hair and nails: Patient denies excessive dryness or sweating, moles/rashes or pruritus.
Head: Patient denies intermittent headaches, vertigo, light-headedness or head trauma.
Eyes: Patient denies visual disturbances, blurring, diplopia, fatigue with use of eyes, scotoma, halos, lacrimation, photophobia or pruritus. Last eye exam unknown. Patient does not wear glasses.
Ears: Patient denies deafness, pain, discharge, tinnitus. Patient does not wear hearing aids.
Nose/Sinuses: Patient denies discharge, epistaxis, obstruction.
Mouth and throat: Patient denies jaw tightness, dry mouth, sore tongue, mouth ulcers, bleeding gums, sore throat or voice changes.
Neck: Patient denies localized swelling/lumps or stiffness/decreased range of motion.
Pulmonary System: Patient denies dyspnea on exertion (DOE), dyspnea (SOB), cough, hemoptysis, cyanosis, orthopnea or paroxysmal nocturnal dyspnea (PND).
Cardiovascular System: Reports HTN. Patient denies chest pain, palpitations, irregular heartbeat, edema/swelling of ankles or feet, syncope or known heart murmur.
Gastrointestinal System: Reports abdominal pain / discomfort, diarrhea and rectal bleeding / blood in stool. Patient denies nausea, constipation, change in bowel habits, vomiting, changes in appetite, intolerance to specific foods, dysphagia, pyrosis, flatulence, eructations (belching, burping), jaundice or hemorrhoids.
Genitourinary System: Patient denies dysuria, urinary urgency, discoloration or urine, frequency, nocturia, oliguria, polyuria, incontinence, awakening at night to urinate or flank pain.

1. Sexual History
   1. Patient is widowed.

Nervous System: Patient denies headache, seizures, loss of consciousness, sensory disturbances, numbness, parethesias, dysesthesias, hyperesthesias, ataxia, loss of strength, change in cognition / mental status.
Musculoskeletal System: Patient reports pain behind her left knee. Denies swelling and bruising or any history of arthritis.
Peripheral Vascular System: Patient denies peripheral edema, intermittent claudication, coldness or trophic changes, varicose veins or color change.
Hematologic System: Patient denies history of PE, anemia, easy bruising or bleeding, lymph node enlargement. Patient denies blood transfusions.
Endocrine System: Patient denies polyuria, polydipsia, polyphagia, heat or cold intolerance, goiter, excessive sweating.
Psychiatric: Patient denies anxiety, depression/sadness, feelings of helplessness, feelings of hopelessness, lack of interest in usual activities, suicidal ideation, anxiety, obsessive / compulsive disorder. 

GENERAL SURVEY: 60-year-old female A/O x3. Patient appears to be of stated age, well developed, well nourished, pleasant and in no acute distress.

VITALS

BP: 126/81mmHg
R: 16 BPM
P: 72 BPM
SpO2: 97% on RA
Temperature: 97.4 F
Height: 65 in                            Weight: 140 lbs                                                            BMI: 23.29

PHYSICAL EXAM
SKIN: Warm & dry, good turgor. Nonicteric, no lesions, no tattoos.
HAIR: Good quantity and equal distribution.
NAILS: No clubbing, capillary refill <2 seconds throughout.
HEAD: NC/AT nontender to palpation throughout.
EYES: No conjunctival injection, bilaterally, cornea clear. EOMI bilaterally, no discharge.
EARS: Symmetrical & normal size. No evidence of lesions, masses, trauma on external ears. No discharge or foreign bodies in external auditory canals AU. TMs pearly white, intact with light reflex in normal position AU.
NOSE: Symmetrical, no obvious masses, lesions, deformities, trauma, discharge. Nares patent bilaterally, nasal mucosa pink & well hydrated. No discharge noted on anterior rhinoscopy. Septum midline without lesions, deformities, injection or perforation. No evidence of foreign body.
LIPS: pink, moist, no evidence of cyanosis or lesions.
MUCOSA: pink, well hydrated. No masses; lesions noted, No evidence of leukoplakia.
PALATE: pink, well hydrated. Intact with no masses, lesions or scars.
TONGUE: Pink, well papillated, no masses, lesions or deviations noted. Oropharynx well hydrated, no evidence of injection, exudates, masses, lesions, foreign bodies. Tonsils present with no evidence of injection or exudates, tonsilith noted on left tonsil. Uvula pink, no edema, lesions.
NECK: Supple, no lymphadenopathy.
LUNGS: Clear to auscultation bilaterally. Chest expansion symmetrical. No wheezing, rhonci, crackles, rales noted.
HEART: RRR. S1 & S2 normal. No murmurs or gallops noted. Carotid pulses 2+ bilaterally.
ABDOMEN: mild left lower quadrant tenderness radiating into left groin. BS active in all four quadrants. Soft, nondistended.
VASCULAR: The extremities are normal in color, size and temperature. Pulses are 2+ bilaterally in upper and lower extremities. No clubbing or cyanosis noted bilaterally (no C/C B/L).
NEURO: Alert and oriented to person, place and time. Memory and attention intact. No gross deficits.
MUSCULOSKELETAL: Left Knee: no erythema, ecchymosis, edema or acute abnormality noted, FROM with no pain, negative valgus and varus tests, negative anterior and posterior drawer tests. 5/5 strength with sensation intact. Right knee normal.

ASSESSMENT: 60 year old female, with PMH significant for HTN, fibromyalgia, lupus, Reynaud’s disease and carpal tunnel syndrome presents complaining of an eight month history of pain behind left knee, likely due to fibromyalgia, requiring work-up to rule out acute diagnoses.

DIAGNOSTICS:

1. Abdominal CT – referral given to patient, awaiting completion. Scheduled for 7/10/19.
2. Left Lower Extremity Ultrasound – referral given to patient, awaiting completion. Scheduled for 7/10/19.

PLAN:

1. Left Knee Pain
   1. Obtain Left Lower Extremity Ultrasound to rule out Baker’s Cyst
   2. Rest left knee as needed
      1. If pain persists, patient instructed to use NSAIDs q6h
   3. Patient instructed to follow up with a PMD or orthopedist for further evaluation pending ultrasound findings
   4. Discussed Electrical Nerve Stimulation with patient and daughter and instructed patient to follow up with Rheumatologist to discuss next steps for moving forward to treat fibromyalgia pain
   5. Patient instructed to go to the ED if worsening or concerning symptoms develop including signs of fever, worsening knee pain, increased swelling, change in color to extremity, loss of sensation or vomiting & chills
2. Abdominal Pain
   1. Complete Antibiotic course –
      1. Start Ciprofloxacin HCL, 500mg PO, bid, x10 days
      2. Start Flagyl 500mg PO, tid, x10 days
   2. Obtain Abdomen/Pelvis CT to rule out diverticular involvement
   3. Avoid seeds and foods that upset stomach
   4. Patient advised to follow up with PCP
   5. Patient verbalized understanding and ambulated from the office freely, in no acute distress
3. Hypertension
   1. Continue medication as prescribed: Amlodipine Besylate, 10mg PO qd
   2. Continue medication as prescribed: Hydrochlorothiazide, 25mg PO qd
4. Fibromyalgia
   1. Continue medication as prescribed: Dextroamphetamine Sulfate, 10mg PO qd
   2. Follow up with Rheumatologist as needed
5. Lupus, Reynaud’s disease and carpal tunnel syndrome
   1. Follow up with Rheumatologist as needed

Differential Diagnosis

1. Diverticulitis
2. Baker’s Cyst
3. Fibromyalgia Trigger Point Flare (at left knee)
4. Diverticulosis
5. Colon Cancer