HISTORY:

Identifying data:

Date & Time: November 8, 2022 10:00 AM

Full name: Mrs. S.R

Address: Flushing, NY

Date of birth: 12/5/1952

Location: NYPQ, Flushing, NY

Religion: Christian

Marital status: Widowed

Source of information: Self

Reliability: Reliable

Source of referral: Self

Mode of transport: Patient was brought in via car by her son

 

Chief Complaint:

“Short of breath” x 5 days

History of Present Illness:

69 y/o female with PMH of HFrEF and well controlled HTN, HLD, and diabetes brought to the ED 3 days ago c/o dyspnea that began 5 days prior to arrival. Patient states the dyspnea has worsened over the course of 5 days and describes trouble sleeping at night due to worsening SOB. States minimal improvement with using 2 pillows at night. Reports the severity of dyspnea as 5/10 at rest and 8/10 with exertion. Patient reports similar episodes in the past with CHF exacerbations. States symptoms are worsened with lying down. Describes worsening edema of B/L legs day before arrival to ED. States she has been compliant to all medications. Reports decreased activity tolerance and states she has to stop every couple of steps to catch her breath. Patient is a non-smoker and denies alcohol or drug use. Admits to orthopnea, paroxysmal nocturnal dyspnea. Denies chest pain, palpitations, cough, fever, fatigue, syncope, wheezing, recent travel, prolonged immobilization, nausea, vomiting, fatigue, personal or family hx MI.

 

Past Medical History:

• Hyperlipidemia x 15 years, well controlled on medications
• Hypertension x 15 years, well controlled on medications
• Diabetes Mellitus x 15 years, well controlled on medications
• Heart failure with reduced ejection fraction x 3 years
• Immunizations: up to date; Covid vaccines and booster up to date (unknown dates); Flu vaccine received October 2022.

Past Surgical History:

• No surgical history.
• Denies past injuries or blood transfusions.

Medications:

• Carvedilol (Coreg), unknown dosage, for hypertension & heart failure, last dose today
• Furosemide, unknown dosage, for hypertension & heart failure, last dose today
• Glipizide, unknown dosage, for diabetes, last dose today
• Empagliflozin (Jardiance), unknown dosage, for diabetes, last dose today
• Simvastatin, unknown dosage, for hyperlipidemia, last dose today
• Denies use of herbal supplements.

Allergies:

• NKDA, no food or environmental allergies.

Family History:

• Mother – Deceased at age 92, natural causes, hx of HTN.
• Father – Deceased at age 87, natural causes, hx of HTN, HLD
• Maternal/paternal grandparents – Decreased at unknown age & unknown reasons
• Son – Age 41, alive and well.
• Son – Age 35, alive and well.
• Son – Age 30, alive and well

Social History:

• Habits – Denies caffeine use. Nonsmoker, denies alcohol or drug use.
• Travel – No recent travel.
• Marital history – Widowed
• Occupational history – Retired elementary school teacher
• Home situation – Lives with family in apartment in Queens, NY.
• Diet – Admits to diet consisting of 3 meals a day that she cooks, including vegetables and protein and grains.
• Sleep patterns – Admits to average sleep pattern (7-8 hrs day)
• Exercise – Admits to minimal daily exercise, usually consisting of walking 2 blocks to park and back.
• Safety measures – Admits to seat belt use.

Review of Systems:

• General: Denies generalized weakness/fatigue, fever, chills, night sweats, weight loss or gain, changes in appetite.
• Skin, hair, nails: Denies changes in texture, excessive dryness or sweating, discolorations, pigmentations, moles/rashes, pruritus, changes in hair distribution.
• Head: Denies headaches, head trauma, vertigo.
• Eyes: Last eye exam 6 months ago. Admits to reading glasses use. Unknown visual acuity. Denies lacrimation, pruritus, visual disturbances, photophobia.
• Ears: Denies deafness, pain, discharge, tinnitus, hearing aid use.
• Nose: Denies discharge, obstruction, epistaxis.
• Mouth/throat: Last dental exam about 2 months ago. Denies voice changes, bleeding gums, sore tongue, sore throat, mouth ulcers, dentures use.
• Neck: Denies localized swelling/lumps, stiffness/decreased ROM
• Breast: Denies lumps, nipple discharge, pain.
• Pulmonary: Admits to dyspnea, dyspnea on exertion, orthopnea, paroxysmal nocturnal dyspnea. Denies cough, wheezing, cyanosis, hemoptysis.
• Cardiovascular: Admits to edema/swelling of ankles or feet, hx of HTN, visits cardiologist regularly for heart failure management. Denies chest pain, palpitations, irregular heartbeat, syncope, known heart murmur.
• Gastrointestinal: Has regular bowel movements daily. Last colonoscopy exam 3 years ago. Denies change in appetite, intolerance to specific foods, nausea, vomiting, dysphagia, pyrosis, unusual flatulence or eructations, abdominal pain, diarrhea, jaundice, hemorrhoids, constipation, rectal bleeding, or blood in stool.
• Genitourinary: Denies urinary frequency, urinary urgency, nocturia, oliguria, polyuria, dysuria, incontinence, flank pain, hematuria, history of hernias.
• Menstrual/Obstetrical: G3, P(T3 P0 A0 L3), menarche age 15, LMP age 55. Denies hot flashes/associated menopause symptoms, breakthrough bleeding, vaginal discharge.
• Sexual History: Denies being sexually active in over 10 years. Denies history of STIs.
• Musculoskeletal: Denies arthritis, muscle pain, deformity or swelling, redness.
• Nervous system: Denies seizures, headache, loss of consciousness, sensory disturbances, ataxia, loss of strength, change in cognition/mental status/memory.
• Peripheral vascular: Admits to B/L leg peripheral edema. Denies intermittent claudication, varicose veins, coldness or trophic changes, color changes.
• Hematologic: Denies anemia, easy bruising or bleeding, lymph node enlargement, blood transfusions, history of DVT/PE.
• Endocrine: Denies polyuria, polydipsia, polyphagia, heat or cold intolerance, excessive sweating, goiter, hirsutism.
• Psychiatric:  Denies depression/sadness, anxiety, OCD, or ever seeing a mental health professional.

 

PHYSICAL:

General: Overweight female, neatly groomed, appears her stated age of 69.

Vital Signs:

BP:                  R                                 L

Seated             124/75                         130/80

Supine             125/80                         125/80

R: 14/min, unlabored                          P: 70 beats/min, regular

T: 98.6 degrees F (oral)                      O2 Sat: 98% Room air

Height: 64in    Weight: 165 lbs          BMI: 28.3

Skin: Warm & moist, good turgor. Nonicteric, no lesions noted, no scars, no tattoos.

Hair: Short, black hair, average quantity and distribution.

Nails: No clubbing, capillary refill < 2 seconds in upper and lower extremities.

Head: Normocephalic, atraumatic, non-tender to palpation throughout.

Ears: Symmetrical and appropriate in size. No lesions, masses or trauma on external ears. No discharge or foreign bodies on external auditory canals AU. TM pearly grey and intact with light reflect in good position AU. Auditory acuity intact to whispered voice AU. Weber midline. Rinne reveals AC > BC AU.

Nose: Symmetrical. No masses, lesions, deformities, trauma or discharge. Nares patent bilaterally, nasal mucosa pink & well hydrated. No discharge noted on anterior rhinoscopy. Septum midline without lesions, deformities, injection or 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.

Mucosa: Pink, well hydrated. No masses or lesions noted. No leukoplakia.

Palate: Pink, well hydrated. Palate intact with no lesions, masses, scars.

Teeth: Good dentition, no obvious dental caries noted.

Gingivae: Pink, moist. No hyperplasia, masses, lesions, erythema, or discharge.

Tongue: Pink, well hydrated. No masses, lesions or deviation.

Oropharynx: Well hydrated. No injection, exudates, masses, lesions or foreign bodies. Tonsils grade 2 present with no injection or exudate. Uvula pink, no edema or lesions.

Neck: Trachea midline. No masses, lesions, scars, or 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.

Eyes: Symmetrical OU. No strabismus, exophthalmos or ptosis.  Sclera white, cornea clear, conjunctiva pink.
Visual acuity uncorrected – 20/25 OS, 20/25 OD, 20/25 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.

Cardiac: JVP is 4 cm above the sternal angle with the head of the bed at 30°. PMI in 5^th ICS in mid-clavicular line. Carotid pulses are 2+ bilaterally without bruits. Regular rate and rhythm (RRR). S1 and S2 are distinct with no murmurs, S3 or S4. No splitting of S2 or friction rubs appreciated.

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: B/L rales on auscultation. Chest expansion and diaphragmatic excursion symmetrical. Tactile fremitus symmetric throughout.

Abdomen: Abdomen flat and symmetric with no striae or pulsations noted. Bowel sounds normoactive in all four quadrants with no aortic/renal/iliac or femoral bruits. Non-tender to palpation and tympanic throughout, no guarding or rebound noted. No hepatosplenomegaly to palpation, no CVA tenderness appreciated.

Breast: Symmetric, no dimpling, no masses to palpation, nipples symmetric without discharge or lesions. No axillary nodes palpable.

Female 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. 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.

Cranial Nerves: CN I- X11 are intact

Peripheral Neurologic Exam

Motor/Cerebellar – Full active/passive ROM of all extremities without rigidity or spasticity. Symmetric muscle bulk with good tone. No atrophy, tics, tremors or fasciculation. Strength 5/5 throughout.  Rhomberg negative, no pronator drift noted. Gait steady with no ataxia. Tandem walking and hopping show balance intact. Coordination by rapid alternating movement and point to point intact bilaterally, no asterixis

Sensory – Intact to light touch, sharp/dull, and vibratory sense throughout.   Proprioception, point localization, extinction, stereognosis, and graphesthesia intact bilaterally

Reflexes – 2+ throughout, negative Babinski, no clonus appreciated

Meningeal Signs – No nuchal rigidity noted. Brudzinski’s and Kernig’s signs negative

Mental status exam: Patient is well appearing, good hygiene and neatly groomed. Patient is alert and oriented to name, date, time and location. Speech and language ability intact, with normal quantity, fluency, and articulation. Patient denies changes to mood. Conversation progresses logically. Insight, judgement, cognition, memory and attention intact.

Peripheral Vascular: 2+ pitting edema notes B/L. The extremities are normal in color and temperature. Pulses are 2+ bilaterally in upper and lower extremities. No bruits noted. No clubbing, cyanosis. No stasis changes or ulcerations noted. No calf tenderness bilaterally, equal in circumference. Homan’s sign not present bilaterally. No palpable cords or varicose veins bilaterally. No palpable inguinal or epitrochlear adenopathy.

Musculoskeletal: No 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.

 

Differential Diagnosis:

• CHF exacerbation – pt has risk factors (hx of HF, HTN, HLD). States that current symptoms are similar to past exacerbations.
• Pulmonary Embolism – patient has risk factors. Also has lower extremity swelling. However, swelling is B/L so less likely.
• Pneumonia – patient has risk factors and worsening SOB. No systemic symptoms present.
• Influenza – given the time of year and pts comorbidities would be important to rule out.
• Pneumothorax – c/o dyspnea. Less likely due to a more gradual onset of SOB. No decreased breath sounds noted on PE. No chest pain.
• ACS – risk factors, no family hx, no chest pain but because of age could be an atypical presentation.
• Pericardial effusion – c/o dyspnea at rest/exertion.

Assessment:

69 y/o F w/ hx of HFrEF, HTN, HLD, diabetes c/o worsening SOB x 5 days. B/L rales and 2+ B/L pitting edema noted on physical exam.

Plan:

• Place pt on cardiac and pulse ox monitoring
• Obtain labs – CBC, CMP, BNP (if elevated likely CHF exacerbation), troponin, ABG, lactic acid, PT/PTT, T/S
• Rapid flu/COVID test
• Chest Xray – to look for signs of cardiomegaly, increased pulmonary vasculature, r/o pneumonia or pneumothorax
• Calculate Wells Criteria score +/- PERC score for risk of PE
• EKG – to r/o ACS or looking for other abnormalities
• Echocardiogram – calculate ejection fraction, can r/o effusion
• Admit pt to floor and cardiology consult
• Continue current meds & increase dosage of Lasix, administer oxygen to help with dyspnea, nitrates
• Repeat chest xrays daily