History
Identifying Data:
Full Name: D.D.
Address: N/A
Date of Birth: N/A
Date & Time: 11/07/2022, 9:00 am
Location: Queens Presbyterian Hospital
Religion: N/A
Source of Information: Self
Reliability: Reliable
Source of Referral: Self
Mode of Transport: N/A
Chief Complaint: “I’m here because I’m going to have surgery because I am unable to have an erection” for the past 10 years.
History of Present Illness:
61 year old male with PMH of GERD, rheumatoid arthritis, BPH, arterial insufficiency, and asthma. Pt presents today for penile prosthetic insertion pre-op work-up. Notes he has had erectile dysfunction for the past 10 years. Admits to trying and failing multiple therapies including Viagra and BPH medications. Denies any alleviating or aggravating factors. Also denies any pain or intermittent claudication. Denies h/o smoking, HLD, heart disease, HTN, PAD, prostate cancer, or DM. Currently on aspirin, omeprazole, folic acid, methotrexate, and etanercept. (I know I don’t have all the parts to OLDCARTS here, but I was in pre-admission testing so it’s kind of difficult to do so in that department)
Past Medical History:
Rheumatoid arthritis x 10 years, on folic acid 1mg PO daily, methotrexate 7.5mg PO weekly, entanercept 50mg injection once weekly
BPH x 8 years, not any medications
Nasal polyps x 12 years, montelukast 10mg PO daily, fluticasone 50mcg twice daily
Hiatal hernia x 5 years
Asthma x 40 years, albuterol 90mcg as needed
GERD x 6 years, omeprazole 20mg PO daily
Arterial Insufficiency, aspirin 81 mg PO daily
Childhood Illnesses- N/A
Immunizations – Up to date; flu vaccine yearly, COVID vaccine (most recent March. 2021)
Screening test and results – Screening colonoscopy 2021, benign.
Past Surgical History:
Nasal polypectomy about 10 years ago, no complications.
Denies any blood transfusions.
Medications:
Omeprazole 20mg PO daily
Folic acid 1mg PO daily
Methotrexate 7.5mg PO weekly
Entanercept injection 50mg once weekly
Sulindac 150mg twice daily
Albuterol 90mcg as needed
Montelukast 10mg PO once daily
Fluticasone 50mcg twice daily
Topiramate 25 mg PO once daily
Denies use of herbal supplements.
Allergies:
NKDA
Family History:
Mother – 82 years old, alive and well
Dad – Deceased at 68, prostate cancer
No children.
Maternal/paternal grandparents – Deceased at unknown age & unknown reasons
Family history of cancer. Denies family h/o diabetes and myocardial infarctions.
Social History:
Mr. NR is single. Lives alone.
Habits – Denies tobacco use. No history of alcohol abuse, denies history of illicit substances. Denies 1cup of caffeine a day.
Travel – No recent travel.
Diet – He states he has a well-balanced diet.
Exercise – Exercises 1-2 x week.
Safety measures – Admits to wearing a seatbelt.
Sexual Hx – Pt is heterosexual. He has not been sexually active for the last few years.
Denies history of sexually transmitted diseases.
Review of Systems:
General –Denies recent weight loss or gain, fever or chills, night sweats, loss of appetite, or 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 headache, vertigo, or head trauma.
Eyes – Denies lacrimation, pruritus, visual disturbances or photophobia. Does not wear glasses. Does not recall when his last eye exam was or what his visual acuity or pressure is.
Ears – Denies deafness, pain, discharge, tinnitus or use of hearing aids.
Nose/sinuses – Denies discharge or epistaxis. Notes he suffers from recurrent nasal polyps.
Neck – Denies localized swelling/lumps or stiffness/decreased range of motion
Breast – Denies lumps, nipple discharge, or pain.
Mouth/throat – Denies bleeding gums, sore tongue, sore throat, mouth ulcers, voice changes or use dentures. Does not recall when last dental exam was.
Pulmonary system – Denies dyspnea, dyspnea on exertion, cough, wheezing, hemoptysis, cyanosis, orthopnea, or paroxysmal nocturnal dyspnea (PND).
Cardiovascular system –Denies irregular heartbeat, chest pain, edema/swelling of ankles or feet, syncope or known heart murmur.
Gastrointestinal system – Usually has regular bowel movements daily. Denies nausea, diarrhea and abdominal pain. Denies change in appetite, vomiting, intolerance to specific foods, dysphagia, pyrosis, unusual flatulence or eructations, jaundice, hemorrhoids, or constipation. Colonoscopy 2021, benign.
Genitourinary system – Denies nocturia, dysuria, urinary frequency, urgency, oliguria, polyuria, incontinence, or flank pain.
Menstrual/Obstetrical – N/A
Musculoskeletal system – Admits to muscle/joint pain from rheumatoid arthritis. Denies deformity or swelling, or redness.
Nervous –Denies seizures, headache, ataxia, loss of strength, change in cognition / mental status / memory, or weakness.
Peripheral vascular system – Denies peripheral edema, intermittent claudication, coldness or trophic changes, varicose veins, or color changes.
Hematological system – Denies anemia, easy bruising or bleeding, lymph node enlargement, or history of DVT/PE. Denies blood transfusion.
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
General: Male appears clean & well-groomed, alert & oriented to time, place, and person. Also has good posture and seems like a reliable source of information. No signs of acute distress, appears as stated age.
Vital Signs: BP: (R) Seated 125/80 P: 80 beats/min, regular
(L) Seated 120/80
R: 16 breaths/min, unlabored O2 Sat: 98.8% Room Air
T: 36.8 degrees C (oral)
Height: 68 inches Weight: 160 lbs BMI: 24.3
Head, Skin, & Nails
Hair: Average quantity and distribution. White color. Straight texture. No evidence of lice or seborrheic dermatitis.
Skin: Warm and moist, smooth texture, good turgor.
Nails: No clubbing, capillary refill <2 seconds in upper and lower extremities
Head: Normocephalic, atraumatic, non-tender to palpation throughout.
Eye Exam
Eyes – Symmetrical OU. No strabismus, exophthalmos or ptosis. Sclera white, cornea clear, conjunctiva pink. Visual acuity uncorrected – 20/25 OS, 20/25 OD, 20/55 OU. Visual fields full OU. PERRLA, EOMs intact with no nystagmus.
Fundoscopy – Red reflex intact OU. Cup to disk ratio< 0.5 OU. No AV nicking, hemorrhages, exudates or neovascularization OU.
Ear Exam
Symmetrical and appropriate in size. No lesions/masses/trauma on external ears. No discharge/foreign bodies in external auditory canals AU. TM’s pearly white/infarct with light reflex in good position AU. Auditory acuity intact to whispered voice AU. Weber midlines/Rhinne reveals AC>BC AU.
Nose & Sinuses Exam
Nose – Symmetrical/no 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/perforation. No foreign bodies.
Sinuses – Non-tender to palpation and percussion over bilateral frontal, ethmoid and maxillary sinuses.
Mouth & Pharynx
Lips – Pink, moist; no cyanosis or lesions. Non-tender to palpation.
Mucosa – Pink ; well hydrated. No masses; lesions noted. Non-tender to palpation. No leukoplakia.
Palate – Pink; well hydrated. Palate intact with no lesions; masses; scars. Non-tender to
Palpation; continuity intact.
Teeth – Good dentition / no obvious dental caries noted.
Gingivae – Pink; moist. No hyperplasia; masses; lesions; erythema or discharge. Non-tender to palpation.
Tongue – Pink; well papillated; no masses, lesions or deviation. Non-tender to palpation.
Oropharynx – Well hydrated; no injection; exudate; masses; lesions; foreign bodies.
Tonsils present with no injection or exudate. Uvula pink, no edema, lesions
Neck Exam
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 cervical adenopathy noted.
Thyroid – Non-tender; no palpable masses; no thyromegaly; no bruits noted.
Thorax & Lungs:
Chest – Symmetrical, no deformities, no trauma, Respirations unlabored/no paradoxic respirations or use of accessory muscles noted. Lat to Ap diameter 2:1. Non-tender to palpation throughout.
Lungs –Clear to percussion & auscultation bilaterally. Chest expansion and diaphragmatic excursion symmetrical. Tactile fremitus symmetric throughout.
Cardiac Exam
Heart: JVP is 2.5cm above sternal angle with the head of the bed at 30 degrees. PMI in 5th ICS in midclavicular line.Carotid pulses are 2+ bilaterally without bruits. Irregular rate & rhythm. S1 & S2 are distinct with no murmurs, S3 or S4. No splitting of S2 or friction rubs appreciated.
Abdominal Exam: Abdomen flat and symmetric with no scars, striae, or pulsations noted. Bowel sounds normoactive in all four quadrants with no aortic/iliac or femoral bruits. Non-tender to palpation and tympanic throughout, no guarding or rebounding noted. Tympanic throughout, no hepatosplenomegaly to palpation, no CVA tenderness appreciated.
Breast Exam: Breast symmetric and smooth without masses. Nipples without discharge. (Not sure if had to do this, but either way I did not have adequate privacy to do so).
Pelvic Exam:
Genitalia: External genitalia without erythema or lesions. Vaginal mucosa pink without inflammation, erythema or discharge. Cervix parous (or multiparous), pink, and without lesions or discharge. No cervical motion tenderness. Uterus anterior, midline, smooth, non-tender and not enlarged. No adnexal tenderness or masses noted. Pap smear obtained. No inguinal adenopathy.
Rectal: Rectovaginal wall intact. No external hemorrhoids, skin tags, ulcers, sinus tracts, anal fissures, inflammation or excoriations. Good anal sphincter tone. No masses or tenderness. Trace brown stool present in vault. FOB negative.
Neurologic: Mental status: Patient is alert and oriented to person, place and time. Cranial nerves II-XII intact. Recent and remote memory is intact, attention, abstract thinking, and new learning ability are intact. Pt has good muscle bulk and tone with strength 5/5, no fasciculations. Cerebellar: Rapid alternative movements, finger to nose intact. Gait including normal stride, on toes, on heels, and tandem walking intact. Negative Romberg and Pronator Drift. Sensory: Pinprick, light touch, graphesthesia, stereognosis, position and vibration intact bilaterally. ( Pt was in a rush to leave for work and couldn’t do the whole physical exam.)
Reflexes:
| Biceps | Triceps | Brachioradialis | Patellar | Ankle/Achilles | Babinski | |
| Right | 2+ | 2+ | 2+ | 2+ | 2+ | absent |
| Left | 2+ | 2+ | 2+ | 2+ | 2+ | absent |
Peripheral Vascular: The extremities are normal in color, size and temperature. Pulses are 2+ bilaterally in upper and lower extremities. No bruits noted. No clubbing, cyanosis or edema noted bilaterally (no C/C/E B/L) No stasis changes or ulcerations noted.
Musculoskeletal (Upper Extremity): No soft tissue swelling / erythema /
ecchymosis / atrophy / or deformities in bilateral upper and lower extremities. Non-tender to palpation / no crepitus noted throughout. FROM (Full Range of Motion) of all upper and lower extremities bilaterally. No evidence of spinal deformities.
Assessment: 61 y/o male w/ PMH of GERD, rheumatoid arthritis, BPH, arterial insufficiency, and asthma presents for penile prosthetic insertion pre-op work up for erectile dysfunction most likely due to arterial insufficiency.
DDx:
- Diabetes
- Can lead diabetic neuropathy which can disrupt neural pathways necessary for an erection.
- PAD
- Erectile dysfunction is often an early indicator of peripheral artery disease, and pt suffers from arterial insufficiency which can cause ED (although he had not mentioned that to me initially).
- Peyronie’s Disease
- Peyronie’s is strongly associated with ED. It can cause pain, penile deformity, and sexual dysfunction.
- Psychogenic
- Sometimes ED can be due to performance anxiety, depression, relationship conflict, loss of attraction, sexual inhibition, conflicts over sexual preference, sexual abuse in childhood, and fear of pregnancy or sexually transmitted disease.
- Andropause
- Pt is 61 so at this point he could have lower levels of testosterone causing erectily dysfunction.
Plan: Order CBC, CMP, PT, UA, Urine culture, free testosterone, ABI, and EKG. Follow-up with PCP to get clearance for surgery.
