Tiffany Liang

Long Term Care H&P 2

Professor Davidson

October 28, 2022 

Identifying Data :

Full Name: Ms. GK

Address: Bronx, NY

Date of Birth: 4/21/1935

Age: 87 yo

Date & Time: October 18, 2022 1:30 pm

Location: Metropolitan Hospital, NY

Religion: None

Source of Information: Self & Son

Reliability: Good

Chief Complaint : “Difficulty breathing,” x 1 week. 

History of Present Illness

87 yo female patient, living with son and his family in an apartment, ambulating with a walker and assistance in ADLs (dressing, bathing, toilet) with a PMHx of aortic stenosis, heart failure with preserved ejection fraction, asthma, hypertension, chronic kidney disease stage 3b, GERD, and osteoarthritis presents with her daughter to the clinic complaining of shortness of breath x 1 week. Patient’s son explained that she was hospitalized last month for asthma exacerbation. Patient and her son state that the asthma was well-controlled and does not remember the medications given at the hospital. However, patient continues to experience difficulty breathing that is associated with weakness. Patient takes 2 puffs of albuterol inhaler up to 3 times a day with relief of symptoms. Patient is a non-smoker. Denies wheezing, wet cough, fever, body aches, headache, chest pain, chest palpitations, trauma to the chest area, changes in vision, diaphoresis, constipation, diarrhea, nausea, vomiting, abdominal pain, fever, or changes in appetite. Denies recent travels. 

Past Medical History

• Aortic Stenosis
• Asthma
• Chronic Kidney Disease Stage 3b
• Essential Hypertension
• Gastroesophageal Reflux Disease
• Glaucoma
• Heart Failure with PReserved Ejection Fraction
• Hyperlipidemia
• Obesity
• Osteoarthritis
• Prediabetes

Past Surgical History

• Total Bilateral Knee Replacement 

Medications

• Methanol 16% Topical Cream 
• Clotrimazole (Lotrimi) 1% Topical Cream BID
• Losartan (Cozaar) 100 mg PO QID
• Metoprolol (Toprol) 100 mg PO QID
• Atorvastatin (Lipitor) 40 mg PO QID
• Aspirin 81 mg PO QID
• Duloxetine (Cymbalta) 30 mg PO QID
• Albuterol (Proventil HFA) Inhale 2 puffs q 6 hours
• Montelukast (Singulair) 10 mg tablet PO QID 

Allergies

• No Known Allergies

Family History

• Mother – aged 82 deceased, coronary artery disease, diabetes type II
• Father – aged 78 deceased, hypertension
• Sister – age 85 alive, hypertension, diabetes type II

Denies family history of cancer.

Social History

Patient is a widowed 87 year old female who currently resides in an apartment with her son and his family in New York, NY. Patient is retired and lives a sedentary lifestyle. 

Habits : Denies drinking, smoking, use of drugs, or marijuana.

Travel : Denies recent travel. 

Diet : Patient eats a diet heavy in carbs and protein with a side of vegetables.

Exercise : Patient maintains a sedentary lifestyle. Patient uses a walker and can walk one block before feeling out of breath. Patient requires assistance going up a flight of stairs. 

Sexual History : Heterosexual, widowed and not sexually active. Denies history of sexually transmitted diseases.

Review of Systems

General – Female patient appears alert, tired, good color, and in mild distress upon movement. Denies recent changes to appetite, fever, constipation, and diarrhea.

Skin, hair, nails – Denies erythema, edema, dryness, pruritus, sweating, scars, lacerations, lesions, or moles.

Head – Denies headaches, dizziness, head trauma, coma, or fractures. Last eye exam – unknown.

Ears – Endorses difficulty of hearing. Denies pain, discharge, tinnitus, or use of hearing aids. 

Nose/sinuses – Denies discharge, obstruction, or epistaxis. 

Mouth/throat – Endorses use of a full set of dentures. Denies difficulty swallowing, bleeding gums, sore tongue, sore throat, mouth ulcers, voice changes. Last dental exam – 1 year ago. 

Neck – Denies stiffness, pain, swelling, and limited range of motion.

Breast – Denies lumps, pain, or discharge.

Pulmonary System – Endorses shortness of breath. Hospitalization one month ago for asthma exacerbation. Denies dry cough, wheezing, hemoptysis, cyanosis, or paroxysmal nocturnal dyspnea (PND). 

Cardiovascular System – History of hypertension and hypercholesterolemia. Denies chest pain, palpitations, syncope, and edema.

Gastrointestinal System – Denies abdominal pain, dysphagia, nausea, vomiting, diarrhea, or constipation. Denies intolerance to specific foods, pyrosis, hemorrhoids, constipation, rectal bleeding.  

Genitourinary System – Denies urinary frequency or urgency, nocturia, oliguria, polyuria, dysuria, awakening at night to urinate or flank pain. 

Nervous System– Denies seizures, headache, or loss of consciousness.

Musculoskeletal System – Endorses need for an assistive walking device due to weight and pain upon ambulation. Endorses full range of movement with discomfort. Denies numbness or tingling. Denies ecchymosis, atrophy, or deformities in bilateral upper and lower extremities.  

Peripheral Vascular System – Denies coldness or trophic changes, peripheral edema, or color changes.

Hematological System – Denies ecchymosis, lymph node enlargement, history of anemia, history of DVT/PE. 

Endocrine System – Denies polyuria, polydipsia, polyphagia, history of hyperthyroidism, history of hypothyroidism, goiter, heat or cold intolerance, or excessive sweating.

Psychiatric – Endorses history of depression treated with Cymbalta. Denies current suicidal ideation. Denies homicidal thoughts.

Physical Exam

General: Female patient appears alert, tired, good color, and in mild distress upon movement. Appears well-developed, well-nourished, and hydrated. Appears stated age.

Skin: Warm, good turgor, and good color. Non-icteric, no scars, lesions, masses, tattoos, or bruising.

Nails: Clean cut. Capillary refill is normal and <2 seconds throughout. No clubbing, splinter hemorrhages, beta lines, koilonychia, or paronychia.

Head: Skull is normocephalic and non-tender to palpation. Hair is full, average texture, and average luster.

Eyes: Cataracts present bilaterally. Sclera is white and conjunctiva is a pale pink. Pupils are equal, round, reactive to light. EOMs are full with no nystagmus or strabismus. 

Visual Acuity : Uncorrected – 20/25 OS, 20/25 OD, 20/25 OU

Fundoscopy : Red reflex is present. Cup:Disk <0.5 OU. Neovascularization presents OU. No AV nicking, papilledema, hemorrhage, exudate, or cotton wool spots.

Ears: Difficulty engaging in conversation due to diminished hearing. Whisper test presents diminished hearing bilaterally. Presence of yellow cerumen. External auditory canals are non-tender to touch. Tympanic membranes are intact with a good cone of light. Weber test heard midline with no lateralization. Rinne test showed AC>BC bilaterally. 

Nose: Nose and sinuses were non-tender to palpation. No signs of nasal swelling or deviation. 

Lips: Pink, moist. No cyanosis, masses, lesions, swelling, or fissures. 

Mucosa: Pink, dry. No mass or lesions noted. No leukoplakia. No thrush.

Palate: Pink, dry. No lesions, masses, scars.  

Teeth: Full set of dentures. 

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

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

Oropharynx: Well hydrated. No exudate, masses, lesions, foreign bodies. Tonsils present with no injection or exudate, Grade 0.  Uvula pink, no edema.

Neck – Full range of motion and non-tender to palpation. Trachea midline. No masses, lesions, scars, pulsations noted.  No cervical adenopathy noted. Lymph nodes are mobile, discrete, and non-tender to palpation.

Thyroid – No goiter or lumps. Non-tender to palpation. 

Chest: Symmetrical. No deformities or trauma. Respirations are unlabored. No paradoxic respirations or use of accessory muscles. Lateral to AP diameter 2:1. Non-tender to palpation throughout.

Respiratory: Clear to auscultation and percussion bilaterally. Chest expansion and diaphragmatic excursion symmetrical. Tactile remits are symmetric throughout. No adventitious sounds.

Cardiovascular: JVP is 2 cm above the sternal angle with the head of the bed at 30°. PMI in 5th 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.

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

Genitalia:  Unable to obtain without chaperone. 

Rectal:   Unable to obtain without chaperone. 

Neurologic: 

Mental Status: Patient is alert, oriented, and attentive. Speech is clear and fluent. 

Cranial Nerves :

CN I : Olfaction is intact by identifying the smell of coffee grounds and vanilla extract. 

CN II: Visual fields are full to confrontation. Fundoscopic exam is normal with sharp discs. Neovascularization present bilaterally.  Venous pulsations are present bilaterally. Pupils are 3-5 mm and briskly reactive to light. Visual acuity is 20/25 uncorrected bilaterally.

CN III, IV, VI: At primary gaze, there is no superior, inferior, lateral, or medial eye deviation. Negative for diplopia and ptosis. Convergence is intact. 

CN V: Facial sensation is intact to pinprick in all 3 divisions bilaterally. Corneal responses are intact.

CN VII: Face is symmetric with normal eye closure and smile. Taste of salty & sweet is present in the anterior 2/3 of the tongue. 

CN VIII: Hearing is diminished, but intact. Whisper test presents diminished hearing bilaterally. Weber test heard midline with no materialization. Rinne test showed AC>BC bilaterally. 

CN IX, X: Palate elevates symmetrically. Phonation is normal.

CN XI: Head turning and shoulder shrug are intact.

CN XII: Tongue is midline with normal movements and no atrophy.

Mini-Cog: Clock Drawing 0/2. Word Recall ⅔. 

Depression PHQ-9: 12/27. Endorses feeling tired, trouble sleeping, and little interest in doing things everyday. 

Motor/Cerebellar :

Full range of motion with discomfort and not accompanied with spasticity. Symmetric muscle bulk with good tone. No atrophy, tics, tremors or fasciculation. Strength 5/5 throughout. Coordination by rapid alternating movement, heel to shin, and point to point intact bilaterally. No asterixis.

Sensory :

Bilateral feet sensory intact with pulses. Intact to light touch, sharp/dull, and vibratory sense throughout. Proprioception, point localization, extinction, stereognosis, and graphesthesia intact bilaterally.

Reflexes :

R L R L

Brachioradialis 2+ 2+ Patellar 0 0

Triceps 2+ 2+ Achilles 0 0

Biceps 2+ 2+ Babinski Present Present

Abdominal 2+/2+ 2+/2+ Plantar Normal  Normal

Clonus negative

Meningeal Signs :

No nuchal rigidity noted. Brudzinski’s and Kernig’s signs are negative.

Musculoskeletal : 

1+ pitting edema present in ankles bilaterally. Full active range of motion of spine and extremities with discomfort. Difficulty ambulating secondary to weight and pain. No soft tissue erythema, ecchymosis, atrophy, or deformities in bilateral upper and lower extremities. No crepitus in all upper and lower extremities bilaterally. 

Vitals

Blood Pressure – 135/60, Temp – 97.7 °F, SpO2 – 97%, Respiratory Rate – 18, Heart Rate – 72, Height – 5’ 0”, Weight – 215 lbs, BMI – 42.0

D/Dx : 

1. Asthma Exacerbation – Patient was recently discharged from hospital due to asthma exacerbation. It is highly likely the patient is experiencing asthma complications due to environmental triggers and recent season changes. 

2. Obesity-Related Difficulty Breathing– Patient is obsese with a BMI of 42.11 that makes walking and moving difficult. Her disposition likely exacerbates breathing efforts, worsens asthma, and contributes to difficulty breathing. 

3. Aortic Stenosis – Patient has a history of aortic stenosis without surgical intervention treatments. This valvular condition can present with shortness of breath and chest discomfort that contribute to her complaint of difficulty breathing. 

4. Heart Failure – Patient has a history of heart failure currently treated with . A heart failure exacerbation of non-compliance with medications could contribute to her difficulty in breathing. However, absence of rales and edema makes this diagnosis less likely. 

5. Myocardial Infarction – Patient presents with a long history of hypertension, coronary artery disease, aortic stenosis, and heart failure. As the patient complains of difficulty breathing, myocardial infarction should be considered. However, the patient does not complain of chest pain, palpitations, or diaphoresis. Furthermore, the shortness of breath has been present for a longer period of time rather than acute onset. This raises a flag to consider myocardial infarction but does not place this diagnosis at the top of differentials. 

Assessment 

87 yo female patient, living with recent hospitalization for asthma exacerbation presents with her son to the clinic complaining of shortness of breath x1 week. Patient reports continued experience of difficulty breathing alleviated with albuterol inhaler. Physical exam is negative for wheezing and use of accessory breathing muscles. EKG was unremarkable. Plan is to focus on lifestyle changes, weight loss, and adherence to asthma medications. 

Problem List & Plan

• Asthma – Shortness of Breath
  • Continue albuterol for relief of symptoms
  • Add Montelukast (Singulair) 10 mg tablet PO QID to control asthma exacerbations
  • Refer to pulmonology to assess pulmonary function and current medications

• Aortic Stenosis
  • Obtain EKG to assess cardiac function
  • Refer to cardiology to monitor aortic stenosis

• Heart Failure with Preserved Ejection Fraction
  • Continue Metoprolol and Lostartan
  • Obtain EKG to assess cardiac function
  • Refer to cardiology to monitor heart failure

• Hypertension
  • Continue Metoprolol and Losartan
  • Recommend patient to  keep daily blood pressure logs to track readings

• Hypercholesterolemia
  • Continue Atorvastatin 
  • Obtain lipid panel to assess current levels

• Pre-Diabetes
  • Obtain HBA1c to assess for current glucose levels
  • Advise patient to eat a diet balanced meals in carbs, protein, and vegetables with reduction in processed sugars
  • Encourage patient to engage in daily light exercise as tolerated

• Chronic Kidney Disease Stage 3b
  • Obtain CMP to assess for renal function and electrolyte status
  • Obtain Urinalysis to assess urinary and renal function
  • Refer to nephrology for monitoring of CKD

• Depression
  • Continue Cymbalta for depression treatment
  • Encourage patient to increase social activities such as engaging with family members or joining a senior center

• Obesity
  • Obtain CBC to assess hemodynamic stability
  • Encourage the patient to try a light form of exercise daily such as slow walks as tolerated
  • Advise weight loss for alleviation of difficulty breathing and co-morbidities 
  • Recommend increased intake of vegetables, fruits, and water