Chief Complaint: Trouble breathing x 5 days
HPI: 84 yo female pt with PMH of HTN and asthma who is independent in ADLs ambulating freely presents to Metropolitan geriatrics accompanied by her husband and son complaining of SOB for the past 5 days. Her son explained that she was hospitalized here at Metropolitan last month for an asthma exacerbation. Pt and her son state that the asthma was well-controlled but can not recall the names of the medications that she was treated with during her hospitalization. Today, she continues to experience difficulty breathing that is associated with fatigue. She admits to taking her albuterol inhaler 2 puffs, 3 times a day with relief of symptoms. She denies ever smoking in the past. She 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 or recent sick contacts.
Past Medical History:
– HTN
– Asthma
Medications:
– Albuterol (Proventil HFA) Inhale 2 puffs q 6 hours
– Losartan (Cozaar) 100 mg PO QID
– Metoprolol (Toprol) 100 mg PO QID
Allergies: – No known drug/food/environmental allergies
Family History:
■ Mother: Deceased age 97. History of HTN and Type 2 DM
■ Father: Deceased age 89. History of HTN
■ 4 children: Healthy
Surgical History:
No surgical history.
Immunization History:
– Pfizer SARS-COV2-Vaccine (2 shots with booster in 2022)
– Pneumovax 23: 04/06/23
– Influenza: 04/06/23
– TDAP: 07/08/20
Social History:
– Smoking: Never
– Alcohol: Never
– Marital History: Married to husband for 62 years.
– Education: Associates degree in college
– Occupational History: Retired, was a substitute teacher
– Travel: No recent travel
– Home situation: Patient lives at home with her husband and one of her sons. Live in an apartment in Brooklyn on the 2nd floor. Takes the stairs to go upstairs.
– Sleep: Patient states she sleeps about 7-8 hours per day.
– Exercise: Walks around the park near her house. Was able to walk for 8 blocks without stopping but now has been feeling slightly fatigued.
– Diet: Diet heavy in carbs and proteins with vegetables.
– Caffeine: 1 cup of coffee daily with half and half milk and splenda.
– Sexual history: Not currently sexually active. No known history of STIs.
Geriatric Assessment:
– ADLs: Independent in all
– IADLs: Dependent in cooking, shopping, and transportation.
– Home Health Aide: None
– Visual impairment: None
– Hearing impairment: None
– Falls in the past year: None
– Assistive devices used: None
– Gait impairment: None
– Urinary incontinence: None
– Fecal incontinence: None
– Cognitive Impairment: None
– Depression: None
– Home safety issues: None
– Health Care Proxy: Yes – her son
– Advance Directives: Full code
ROS:
– General: Admits to fatigue. Denies fever, chills, night sweats, weight loss, changes in appetite. – 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 4 months ago.
– Neck: Denies localized swelling/lumps, stiffness/decreased ROM
– Breast: Denies pain, swelling, discharge.
– Pulmonary: Admits to SOB. Was hospitalized one month ago for asthma exacerbation. Denies cough, dyspnea, wheezing, cyanosis, hemoptysis.
– Cardiovascular: History of HTN. Denies chest pain, edema/swelling of ankles or feet, palpitations.
– Gastrointestinal: Denies abdominal pain, dysphagia, nausea, vomiting, diarrhea, or constipation. Denies intolerance to specific foods, pyrosis, hemorrhoids, constipation, rectal bleeding.
– Genitourinary: Denies urgency, frequency, incontinence, hesitancy, dribbling.
– Musculoskeletal: Denies muscle pain, joint pain, arthritis, or swelling.
– Nervous system: Denies seizures, 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 anemia, 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: Height – 5’ 0”, Weight – 104 lbs, BMI – 20.3 Temp – 97.6 °F, Blood Pressure – 138/64, SpO2 – 98%, Respiratory Rate – 18, Heart Rate – 76
General: 84 y/o female pt A/O x3. Appears stated age. Doesn’t seem to be in any acute distress.
Skin: Warm, good turgor, and good color. Non-icteric, no scars, lesions, masses, tattoos, or bruising.
Nails: Capillary refill is normal and <2 seconds throughout. No signs of clubbing, splinter hemorrhages, beta lines, koilonychia, or paronychia.
Head: Skull is normocephalic and non-tender to palpation.
Eyes: Sclera is white and conjunctiva is a pale pink. Pupils are equal, round, reactive to light. EOMs are full with no nystagmus or strabismus.
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: 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.
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.
Thyroid – Non tender to palpation. 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: 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. Non-tender to palpationm no guarding or rebound noted.
Neurologic: Mental Status: Patient is alert, oriented, and attentive. Speech is clear and fluent. Cranial Nerves : CN II: Visual fields are intact. CN III, IV, VI: Extraoccular muscles intact with full ROM. CN V: Facial sensation is intact. Corneal responses are intact. CN VII: Face is symmetric with normal eye closure and smile. Expressions intact. CN VIII: Hearing is intact to whisper test BL. CN IX, X: Palate elevates symmetrically. CN XI: Head turning and shoulder shrug are intact. Mini-Cog: 5/5 (immediate and delayed recall, clock test)
Motor/Cerebellar : Gait steady, no ataxia or impairment noted. Romberg negative, no pronator drift noted. Get up and go test: < 15 seconds Sensory: Bilateral feet sensory intact with pulses. Intact to light touch, sharp/dull, and vibratory sense throughout. 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
Musculoskeletal: Full active range of motion of spine and extremities without discomfort. No soft tissue erythema, ecchymosis, atrophy, or deformities in bilateral upper and lower extremities. No crepitus in all upper and lower extremities bilaterally.
Assessment/Plan: 84 yo female patient, with recent hospitalization for asthma exacerbation presents with her husband and son to Metropolitan Geriatrics complaining of SOB x 6 days. Patient admits relief with her albuterol inhaler. Physical exam unremarkable for wheezing or any signs of accessory breathing muscles. EKG was unremarkable. Plan is to focus on continue taking albuterol and add on Montelukast for her asthma, continue taking her HTN medications, and administer TD vaccine today.
Asthma: – Continue taking albuterol as needed – Add Montelukast (Singulair) 10 mg tablet PO QID to control asthma exacerbations – Refer to pulmonology to assess pulmonary function and current medications
Hypertension: – Continue Metoprolol 100 mg PO QID – Continue Losartan 100 mg PO QID
Vaccinations/LTC: – Administer TD vaccine – Return for routine follow-up in 3 months.
