History
Identifying Data:
Full Name: GW
Address: Flushing, NYC
Date of Birth: 5/2X/19XX
Date & Time: March 30, 2019 3:21 pm
Location: QHC Flushing, NY
Religion: Hindu
Source of Information: Self
Source of Referral: Self
Mode of Transport: Daughter
PCP: Dr. Dylan, Flushing, NY
Chief Complaint: “cough and can’t catch my breath” x 1 week
History of Present Illness:
GW is a 79 y/o female PMHx HTN x 15 years, CAD, HLD, hypothyroidism, osteoporosis, sciatica, OA, b/l knee replacement, R shoulder tear, b/l carpal tunnel syndrome, sinusitis and GERD who presented to ED 1days ago c/o SOB and productive cough x 1 week. Cough and SOB are associated with subjective fever and chills x 1 week. GW went to her PCP and took OTC cough medicine without alleviation. Movement, inspiration, and coughing exacerbate both cough and SOB. GW was in her usual state of health until 1 week ago when she started to have green nasal discharge and cough. Her PCP gave her OTC cough medicine which did not relieve symptoms. Throughout the last week, the cough became progressively worse and more frequent; by the end of last week her cough was productive with green sputum and subjective fever (patient did not take her temperature at home), chills, and nausea. She had many bouts of NBNB vomiting x 3 days. Cough was also associated with diffuse abdominal RUQ and LUQ pain 2/10 without radiation and with epigastric, intermittent chest pain x 3 days without radiation which patient described as “tight” without alleviating factors. Movement and cough exacerbated both abdominal and epigastric pain. Of note, both abdominal pain and chest pain are absent but patient states she has generalized weakness. GW denies SOB symptoms prior to start of symptoms, hx MI, recent travel, recent hospitalizations, sick contacts, smoking, drug use, hx of PNA, recent weight loss, unusual flatulence or eructation, night sweats, arrthymia, palpitations, peripheral edema, varicose veins, claudication, wheezing, hx of asthma, heartburn, hematochezia, hematemesis, epistaxis, frequent colds, environmental allergies, sore throat, hoarseness, lymphadenopathy, night sweats, cyanosis, hx of emphysema/bronchitis, dysphagia, constipation, diarrhea, changes in bowel habits, food intolerance, anemia, changes in appetite, DM, heat/cold intolerance, jaundice, hemorrhoids, rectal bleeding. Denies urinary frequency or urgency, nycturia , oliguria, polyuria, dysuria, incontinence, awakening at night to urinate or flank pain, orthopnea, or paroxysmal nocturnal dyspnea (PND).
Past Medical History:
Past medical illnesses
HTN 4/2006
CAD 2010
GERD 5/2010
HLD 5/2010
Cervical spine degeneration 4/15/2016
Post partial thyroidectomy 4/15/2016
Osteoporosis 4/2016
R Shoulder impingement 4/15/2016
L Shoulder impingement 1/5/2018
Spondylosis of cervical region without myelopathy or radiculopathy 1/5/2018
Vitamin D deficiency
Childhood illnesses – Chicken pox at age 5.
Immunizations – Up to date; flu vaccine yearly.
Screening tests and results: Colonoscopy 1/6/2016
Past Surgical History:
L Ankle surgery 2010
Myomectomy abdominal approach
Colonoscopy with Polypectomy Queens Hospital 10/14/2016
Thyroidectomy
B/L total knee arthroplasty 2005
Denies past injuries, complications or transfusions.
Medications:
Atorvastatin 20 mg x 1 tab PO qd for HLD
Docusate sodium 100 mg x 2 capsules PO qd for constipation
Fluticasone propionate 50 mcg/act nasal spray x 1 application x 2 spray for rhinitis
Lansoprazole 30 mg x 1 capsule qd for GERD
Levothyroxine 75 mcg x 1 tab qd for hypothyroidism
Losartan 50 mg x 1 tablet qd for HTN
Denies supplement use.
Allergies:
Lisinopril Cough
Motrin Chest pain and stomach upset
Denies environmental or food allergies.
Family History:
Mother – Deceased 88 HTN, arthritis
Father- Deceased, 81 HTN
Brother Alive and Well 70
Daughter Alive and Well 50 HLD, HTN
Denies family history of cancer, DM
Social History:
GW is a 79 y/o Indian female living with daughter in Flushing. Patient is ambulatory at baseline with assistance x 2 blocks.
Habits – No drug, alcohol, or caffeine use.
Travel – Denied recent travel.
Diet – eats well-balanced diet with many fruits/veggies.
Exercise – goes on a daily walk in the a.m. She sleeps well about
6-8hours each night.
Safety measures – Admits to wearing a seat belt
Education: High school
Sexual Hx – Widowed. She is not sexually active. Denies history of sexually transmitted diseases.
Review of Systems:
General – See HPI
Skin, hair, nails – Denies changes in texture, excessive dryness or sweating, discolorations,
pigmentations, moles/rashes, pruritus or changes in hair distribution.
Head – Denies headaches, vertigo or head trauma.
Eyes – Patient has reading glasses. Denies lacrimation, other visual disturbances, or photophobia.
Ears – Denies deafness, pain, discharge, tinnitus or use of hearing aids.
Nose/sinuses – See HPI
Mouth/throat – Denies bleeding gums, sore tongue, mouth ulcers, voice changes or use dentures. Last dental exam was 3 months ago.
Neck – Denies localized swelling/lumps or stiffness/decreased range of motion
Breast – Denies lumps, nipple discharge, or pain.
Pulmonary system – See HPI.
Cardiovascular system –See HPI.
Gastrointestinal system – See HPI.
Genitourinary system – See HPI.
Nervous – Denies seizures, headache, loss of consciousness, sensory disturbances, ataxia, loss of strength, change in cognition / mental status / memory, or weakness.
Musculoskeletal system – Denies deformity or swelling, redness.
Peripheral vascular system – Denies intermittent claudication, coldness or trophic changes, varicose veins, peripheral edema or color changes.
Hematological system – Denies anemia, easy bruising or bleeding, lymph node enlargement, or history of DVT/PE.
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: 79 y/o female lying down NAD. Looks apparent age, well-developed and is well-groomed. AAO x 3.
Vital Signs: BP: R
Seated 154/80
R: 20/min unlabored P: 105, regularly regular
T: 37.1 degrees F (oral) O2 Sat: 97% Room air
Skin: warm & moist, good turgor. Nonicteric, no lesions noted, no scars, tattoos.
Hair: average quantity and distribution.
Nails: no clubbing, splinter hemorrages, capillary refill <2 seconds throughout.
Head: normocephalic, atraumatic, non tender to palpation throughout
Eyes – symmetrical OU; no evidence of strabismus, exophthalmos or ptosis; sclera white;
conjunctiva & cornea clear. Visual fields full OU. PERRL , EOMs full with no nystagmus No evidence of A-V nicking, papilledema, hemorrhage, exudate, cotton wool spots, or neovascularization OU.
Nose – Symmetrical / no obvious masses / lesions / deformities / trauma / Nares obstructed bilaterally b/l tenderness on palpation of frontal sinuses/ Nasal mucosa red and well hydrated. Green discharged noted on rhinoscopy. Septum midline without lesions / deformities / injection / perforation. No evidence of foreign bodies.
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 palpable
adenopathy noted.
Thyroid – Non-tender; no palpable masses; no thyromegaly; no bruits noted.
THORAX & LUNGS:
Chest – Symmetrical, no deformities, no evidence trauma. Respirations unlabored / no paradoxical respirations or use of accessory muscles noted. Lat to AP diameter 2:1. Non-tender to palpation.
Lungs – Clear to auscultation and percussion bilaterally. Chest expansion and diaphragmatic excursion symmetrical. Tactile fremitus intact throughout. No adventitious sounds.
Heart: Carotid pulses are 2+ bilaterally without bruits. Tachycardic with regular rhythm (RRR); S1 and S2 are normal. There are no murmurs, S3, S4, splitting of heart sounds, friction rubs or other extra sounds.
Breasts: symmetric, no dimpling, no masses, nipples without discharge. No axillary nodes palpable
Abdomen: Flat / symmetrical / no evidence of scars, striae, caput medusae or abnormal pulsations.
Active BS in all four quadrants. No bruits noted over aortic/renal/iliac/femoral arteries. N/t to palpation and percussion in all 4 quadrants. No evidence of organomegaly. No masses noted.. No CVAT noted bilaterally.
Genitourinary: No rashes, ulcers, scars, nodules, indurations, discharge, scrotal masses, or hernias.
Rectal: Patient Denied
Peripheral Vascular: Skin normal in color and warm to touch upper and lower extremities bilaterally. No calf tenderness bilaterally, equal in circumference. No palpable cords or varicose veins bilaterally. No palpable inguinal or epitrochlear adenopathy. No cyanosis, clubbing / edema noted bilaterally.
Neurological: Mental Status
Alert and oriented to person, place and time. Memory and attention intact. Receptive and expressive abilities intact. Thought coherent. No dysarthria, dysphonia or aphasia noted.
Cranial Nerves intact throughout
Motor/Cerebellar
Full active/passive ROM of all extremities without rigidity or spasticity. Normal muscle bulk and tone. No atrophy, tics, tremors or fasciculations. Strength equal and appropriate for age bilaterally (4/5 throughout). No Pronator Drift. Gait normal with no ataxia.
Sensory and reflexes grossly intact throughout
Reflexes R L R L
Brachioradialis 2+ 2+ Patellar 2+ 2+
Triceps 2+ 2+ Achilles 2+ 2+
Biceps 2+ 2+ Babinski neg neg
Abdominal 2+/2+ 2+/2+ Clonus negative
Meningeal Signs
No nuchal rigidity noted.
Musculoskeletal: No soft tissue swelling / erythema / ecchymosis / atrophy / or deformities in bilateral upper and lower extremities. B/L shoulder tenderness to palpation / no crepitus noted throughout. FROM (Full Range of Motion) of all upper and lower extremities bilaterally. No evidence of spinal deformities.
Labs:
Sodium: 131 (low)
Potassium: 4.1 (normal)
Chloride: 91 (low)
BUN: 17 (normal)
CO2 27 (normal)
Creatinine: 1.02 (normal)
WBC: 5.2 (normal)
Hb: 11.4 (low)
HgA1C 5.4 (normal)
MCV 79.3 (low))
Hct: 35.1 (low)
Troponin <0.010 (normal)
Imagine
CXR 2 views- unchanged cardiomegaly. New right infrahilar opacity d/t infection/pneumonia.
Assessment: 79 y/o female PMHx HTN, HLD, hypothyroidism, osteoporosis, sciatica, OA, b/l knee replacement, R shoulder tear, sinusitis and GERD presents to QHC ED c/o productive cough with discharge with associated fever and chills x 1 week. CXR shows R sided consolidation with 30% bands.
Plan:
- 1. Sepsis d/t LLL streptococcal PNA- most likely due to patient presentation of productive cough, tachycardia, hypertension, 30% bands, R sided consolidation on CXR.
- a. Admit to IM
- b. Repeat vitals q 6 h
- c. Ceftriaxone and azithromycin x 1 + day. I
- d. IVF x 24 H
- e. Duonebs and Oxygen
- f. Symptomatic Tx
- g. Sputum Culture
- h. EKG
- 2. Hyponatremic hypochloremia- possible d/t vomiting hx
- a. i. IVF-
- 3. HTN
- a. Hold metoprolol 25 mg q 12 and losartan 50 mg qd d/t sepsis. Resume if BP is elevated on repeat vitals.
- 4. Hypothyroidism
- a. Continue levothyroxine 75 mg PO qd
- 5. Osteoporosis
- a. Tylenol PO PRN
- 6. GERD
- a. Pantoprazole 40 mg PO qd
- 7. HLD
- a. Atorvastatin 20 mg 1 tab PO qd
- 8. GI PPX
- a. Pantoprazole 20 mg PO qd
- 9. Constipation
- a. Colace 200 mg PO qhs PRN
- 10. CVT PPX
- a. Levenox 40 mg SC qd
- D/DX:1. Sepsis d/t LLL streptococcal PNA -most likely due to 30% bands, CXR LL consolidation, tachycardia, tachypnea, HTN.
2. MI –possible d/t unusual presentation in female and CAD hx unlikely d/t low troponin, fever.
3. TB- possible d/t (+) CXR LLL opacity. Unlikely d/t TB immunizations and lack of military pattern on CXR.
4. atelectasis- possible d/t (+) CXR LLL opacity. Unlikely d/t lack of s/sx of volume loss (patient is HTN).
4. Pericarditis- possible d/t pleuritic CP and low grade fever. Unlikely d/t CXR findings, lack of postural changes in pain.
5. Myocarditis- unlikely but possible d/t viral prodromal presentation of low grade fever, dyspnea.
6. PE d/t HF- unlikely d/t lack of hypotension. Possible d/t acute dyspnea, fever, and pleuritic chest pain and hx of risk factors including HLD and CAD. (+) CXR of LLL lobar opacity.
7. pulmonary edema- (+) CXR LLL Central opacification with peripheral clearing
