H&P #3

Identifying Data

Full Name: A. R.

Sex: Female

DOB: xx/xx/1947

Date & Time: June 12, 2023 3:00 pm

Location: Metropolitan Hospital Center

Religion: Unspecified

Source of Information: Self

Reliability: Reliable

Source of referral: Self

Mode of transportation: Daughter drove patient

 

Chief Complaint: “blood pressure follow up”

 

History of Present Illness:

A. R. is a 75 y/o F who is independent in ADLs ambulating freely to the geriatric clinic with PMHx of type II DM, vitamin D deficiency, HTN, hypothyroidism presenting for follow up visit accompanied by daughter for blood pressure follow up. Patient was last seen in clinic on 6/07/2023 for full visit where BP in office was found to be 91/52. Patient was asymptomatic and denied any dizziness or lightheadedness. Patient’s daughter was reporting systolic BP at home in the 110s, unable to recall diastolic. Patient was advised to hold the amlodipine 5 mg and to continue on losartan 100 mg daily & carvedilol 6.2 mg BID. Patient was prescribed a new BP monitor for home and daughter was advised to log at home BP readings at home for the next week. Patient was asked to return to clinic on 6/12 for BP check while at the hospital for another visit.

Patient reported for BP check today and it was found to be 97/47. Patient’s daughter states she took patient’s BP this morning prior to eating and BP was in 60s/40s. Patient had no symptoms. As per patient’s daughter, patient had stopped the amlodipine 1 week ago and has been compliant with the losartan and carvedilol. Upon review of the BP log from previous week patients BP has been low at home and averages around the 90s/60s at home. Patient’s daughter states she watches patient take medications and does not take more pills than prescribed. Patient denies any acute complaints and reports that she “feels good.” Denies dizziness, lightheadedness, blurry vision, confusion, nausea, vomiting, fatigue, headache, fainting, chest pain, SOB.

 

Geriatric Assessment

  • ADLs: Independent in all
  • IADLs: Dependent in shopping, transportation, paying bills, preparing meals (previously able to)
  • Home Health Aide: None – patient’s daughter states she has followed with social worker and Medicaid in hopes of getting patient a home health aide
  • Visual impairment: Yes – patient wears glasses; following with ophthalmology
  • Hearing impairment: None
  • Falls in the past year: None
  • Assistive devices used: None
  • Gait impairment: Yes – patient walks at slower speed (TUG test over 20 seconds)
  • Urinary incontinence: None
  • Fecal incontinence: None
  • Osteoporosis: Has osteopenia. DEXA (5/7/2018) T score -0.3 AP spine and -2 dual femur
  • Cognitive Impairment: None – Mini-cog: 5/5
  • Depression: None – PHQ 9 completed, score 0/27
  • Home safety issues: Patient home has lots of clutter, daughter is working to reduce it. Home has good lighting. Needs bath rails.
  • Health Care Proxy: Yes – Daugher C. R. (xxx-xxx-xxxx)
  • Advance Directives: Full code

 

Past Medical History

Medical History:

  • Hypertension (2010 – present)
  • Hypothyroidism (2019 – present)
  • Type II Diabetes Mellitus (2016 – present)
  • No past hospitalizations or history of blood transfusions.

Medications:

  • Carvedilol (coreg) 6.25 mg tablet PO BID; for hypertension
  • Cholecalciferol (vitamin D3) 25 mcg (1000 UT) capsule 1 capsule QD; for osteopenia
  • Levothyroxine (Synthroid) 88 mcg 1 tablet PO QD in the morning M-F; for hypothyroidism
  • Losartan (cozaar) 100 mg tablet PO QD; for hypertension
  • Metformin (Glucophage) 500 mg tablet PO BID; for diabetes
  • Multi-vitamin (centrum silver 50+ women) 1 tablet PO QD
  • OTC vitamin B12 1000 mcg
  • Denies herbal supplement use.

Surgical History:

  • No past surgical history

Immunization History:

  • Shingrix: 7/16/21, 8/25/22
  • Zoster: 4/9/14
  • Prevnar 13: 3/18/15
  • Pneumovax 23: 5/29/13
  • Pfizer SARS-COV2-Vaccine: 3/2/21, 3/23/21, 11/16/21
  • Bivalent Pfizer SARS-COV2-Vaccine: 10/13/22
  • Influenza: 10/27/22
  • TDAP: 8/27/12

Allergies:

  • Shellfish allergy; reaction: itching
  • No known drug/environmental allergies

Family History:

  • Mother: Deceased age 83 from DM II.
  • Father: Deceased age 85 from COPD. Hx HTN, HLD, smoker.
  • 1 child: alive and well, living in NY with patient.
  • No known family history of cancer.

Social History:

  • Smoking: Never
  • Alcohol: Never
  • Denies past or current illicit drug use
  • Marital History: Widowed, husband deceased 5 years ago
  • Language: Patient requires Spanish translation, able to read and write
  • Education: High school graduate & one year of college in Puerto Rico
  • Occupational History: Retired, previously a secretary
  • Travel: No recent travel
  • Home situation: Lives with daughter on 5th floor of apartment building with elevator. Patient’s home has a lot of clutter which daughter is attempting to clean up. No carpets. Good lighting. Bath mat.
  • Sleep: Patient states she sleeps well about 7 hours per day.
  • Exercise: Patient does not do much exercise. States she is able to walk 2-3 blocks without stopping.
  • Diet:
    • Breakfast: toast with coffee
    • Lunch: spaghetti
    • Dinner: rice and beans, sometimes has fish, with mixed vegetables
  • Caffeine: 1 cup of coffee daily black.
  • Sexual history: Not currently sexually active. No known history of STIs.

ROS:

  • General: Admits to changes in appetite (patient does not like to eat meat). Denies fatigue, fever, chills, night sweats, weight loss.
  • Skin, hair, nails: Denies discolorations, moles, rashes, changes in hair distribution or texture, pruritus.
  • HEENT: Denies head trauma, vertigo, visual disturbances, ear pain, hearing loss, tinnitus, epistaxis, discharge, congestion, sore throat, bleeding gums. Patient states last dental visit was about 5 months ago. Last ophthalmology visit 1 year ago.
  • Neck: Denies localized swelling/lumps, stiffness/decreased ROM
  • Breast: Last mammogram 8/16/2021 nml. Denies pain, swelling, discharge.
  • Pulmonary: Denies cough, dyspnea, wheezing, cyanosis, hemoptysis.
  • Cardiovascular: Denies chest pain, edema/swelling of ankles or feet, palpitations.
  • Gastrointestinal: Denies abdominal pain, nausea, vomiting, diarrhea, constipation, hematemesis, hematochezia, melena, intolerance to specific foods, anal bleeding. Last colonoscopy 2/15/2022, nml.
  • Genitourinary: Denies urgency, frequency, incontinence, hesitancy, dribbling.
  • Musculoskeletal: Denies muscle pain, joint pain, arthritis, or swelling.
  • Nervous system: Denies headache, loss of strength, change in cognition/mental status/memory.
  • Peripheral vascular: Denies intermittent claudication, varicose veins, coldness of extremities, color changes, peripheral edema.
  • Hematologic: Denies easy bruising or bleeding, lymph node enlargement, history of DVT/PE.
  • Endocrine: Denies polydipsia, polyphagia, heat or cold intolerance, excessive sweating.
  • Psychiatric: Denies depression or anxiety.

 

Physical Exam:

Vitals:

  • Weight: 105 lb Height: 64 inches       BMI: 18.06 kg/m2
  • BP: 97/47, left arm sitting. Repeat 91/52, right arm sitting.
  • RR: 18, unlabored
  • HR: 60, regular
  • Temp: 97.8 F oral
  • SpO2: 98% room air

General: 75-year-old slender female who appears stated age. Well-groomed and good posture. A/O x 3 and appears in no acute distress.

Skin: Warm, dry & intact. No rashes, cyanosis, moles, or lesions noted.

Head: Normocephalic & atraumatic

Eyes: Symmetrical OU. Sclera white, cornea and lens clear and conjunctiva pink. PERRL. EOM intact with no nystagmus.

Ears: Ears symmetric and appropriate in size. No lesions or masses on external ear. TM clearly visualized, pearly grey & in good position AU. Auditory acuity intact to whispered voice AU.

Nose: Symmetrical. No rhinorrhea noted. Nares patent B/L.

Mouth/Throat: Mucus membranes moist. Pharynx non-erythematous. No exudates present.

Neck: Trachea midline. Neck supple and non-tender. No lymphadenopathy present. Carotid pulses 2+. No carotid bruits auscultated. FROM without pain.

Thyroid: Non-tender to palpation, no thyromegaly noted, no palpable nodules or masses.

Heart: Regular rate and rhythm. S1 & S2 distinct with no murmurs or gallops.

Chest: Symmetrical, no deformities. Non-tender to palpation. Chest expansion symmetrical with no accessory muscle use.

Lungs: Clear to auscultation B/L. No adventitious sounds noted.

Abdominal: Abdomen symmetric and non-distended, with no striae or scars. Normoactive bowel sounds in all 4 quadrants. Non-tender to palpation and tympanic throughout with no guarding or rebound. No abdominal hernias noted. No CVA tenderness appreciated.

Neurologic:

  • Mental status: alert and oriented to person, place and time.
  • Mood: No depression, anxiety or suicidal ideations.
  • Cranial Nerves:
    • CN II: visual fields intact to finger counting
    • CN III, IV, VI: PERRL, extraocular muscles intact with full range of movement
    • CN V: normal facial sensation, muscles of mastication are normal and symmetric
    • CN VII: facial musculature is symmetric and expressions intact
    • CN VIII: hearing is intact bilaterally to whisper test
    • CN IX, X: normal palatal elevation, uvula is midline
    • CN XI: sternocleidomastoid muscles are 4/5 bilaterally, trapezius muscles are 4/5 bilaterally
  • Sensation:
    • Light and dull touch: normal, symmetric in bilateral upper and lower extremities
  • Motor/cerebellar:
    • Slow gait speed noted, steady.
    • Romberg negative, no pronator drift noted.
    • Get up and go test: > 20 seconds
  • Reflexes:
    • Bicep: Right 2+/4, Left 2+/4
    • Tricep: Right 2+/4, Left 2+/4
    • Brachioradialis: Right 2+/4, Left 2+/4
    • Patellar: Right 2+/4, Left 2+/4
    • Achilles: Right 2+/4, Left 2+/4
    • Plantar reflex: Babinski negative
  • Mini-Cog: 5/5 (3/3 immediate recall, 3/3 delayed recall, 2/2 clock & time placement)

Musculoskeletal: No soft tissue swelling, erythema, ecchymosis or deformities.

  • Neck/Spine: No muscular atrophy noted. Kyphosis noted to upper thoracic. No evidence of scoliosis. No pain to palpation of spinous processes or paravertebral muscles. Neck flexion, extension, rotation and lateral flexion intact without pain. Spinal flexion and extension intact without pain.
  • Shoulders: No atrophy noted. Flexion/extension 4/5 in strength and abduction/adduction 4/5 strength. External/internal rotation intact without pain.
  • Elbow: No atrophy noted. Flexion/extension 4/5 in strength. No cog-wheel rigidity noted with passive supination/pronation.
  • Hand/wrist: Symmetrical, no swelling, erythema or boney changes noted. No Heberden’s or Bouchard’s nodes present. Flexion and extension of wrist and fingers intact without pain. Grip strength 4/5.
  • Hips: No muscular atrophy noted. Flexion/extension, external/internal rotation and abduction/adduction intact without pain.
  • Knee: No soft tissue swelling or atrophy of quadricep muscle. Flexion/extension 4/5 in strength. External/internal rotation intact without pain.
  • Feet/ankles: No soft tissue swelling or atrophy noted. Inversion/eversion & dorsiflexion/plantar flexion intact without pain.

Peripheral vascular: Extremities are symmetrical and normal in size, color and temperature. No edema or stasis changes noted. Pulses 2+ bilaterally in upper and lower extremities. No calf tenderness.

Foot exam: Skin in warm and intact. No edema, erythema, lesions or ulcers notes. Nails well-trimmed and appropriate in length. 2+ dorsalis pedis and posterior tibial pulses bilaterally.

 

Assessment/Plan:

#Hypertension –

  • Recent BP readings show frequent asymptomatic episodes of hypotension
  • BP today in office: 97/47

Plan:

  • Permanently discontinue amlodipine 5 mg
  • Decrease losartan to 25 mg QD PO
  • Continue carvedilol 6.25 mg BID

 #Type II DM – controlled

  • A1C 6.4
  • Continue metformin 500 mg BID
  • Will repeat A1C in 3 months

 #Hypothyroidism – stable

  • TSH is stable to 3.84

Plan:

  • Continue levothyroxine 88 mcg 5 days a week
  • Continue to follow with endocrine

 #Vitamin B12 deficiency

  • Continue on oral B12 tablets

#Osteopenia  

  • DEXA (5/7/2018) T score -0.3 AP spine and -2 dual femur
  • Patient is currently on vitamin D therapy

Plan:

  • Continue on vitamin D
  • Updated DEXA scan ordered today

 #Health maintenance

  • TD vaccine given today
  • Mammogram referral given & pending
  • Ophthalmology referral given & pending
  • Podiatry referral given & pending

RTC:

  • Return for nurses visit BP check on July 24th
  • Return for regular follow up visit in 3 months and please complete bloodwork (fasting) 1 week prior to visit

/s/ Nia Grant, PA-S