RT6-IM H&P

RT6-Internal medicine H&P

Identification:

Patient’s name: Mrs. K

DOB: 69 years old

Gender: Female

Race: Asian

Location: NYPQ, Flushing, NY

Date and Time: 7/25/2019, 3pm

Informant: self, reliable

CC:  chest pain x 1 day

HPI: A 69 years old Asian female with past medical history of asthma on 2L home O2 (last hospitalized on June 2018), right breast cancer on chemo (last chemo treatment one month ago), and hypothyroidism woke up this morning with chest pain. Pain is described as diffused, soreness, “at times sharp” and similar to the feelings of a panic attack, 5/10 severity without radiation. Patient went to her PCP clinic for chest discomfort, where EMS was activated due to chest pain and hypoxia of 88% saturation. Patient also endorses chronic productive cough with greenish-yellow sputum for about 1 month and associated with some SOB. Denies blood in the sputum. Patient admits she always takes medications as instructed. In ED, patient was given oxygen via nasal cannula, fentanyl IV push once, aspirin once, and she reported feels better with oxygen. The patient’s last asthma attack and hospitalization for asthma were in June 2018. At the time of examination, patient denies chest pain, abdominal pain, nausea, vomit, diarrhea, fever, chill, headache, night sweats.

PMH:

Asthma (last asthma attack and hospitalization June 2018) since childhood

Hypothyroidism x 30s years

Breast cancer on chemo (last chemo one month ago) 2017

Past Surgical History:

Mastectomy 2017

Previous hospitalization for asthma 2018

Medications:

Current facility administrated medications:

Albuterol-ipratropium 2.5 mg-0.5 mg/3 mL inhalation solution inhaled Q6H, PRN

Proair HFA 90mcg/inh inhalation, 2 puff QID

Symbicort 80mcg-4.5mcg/inh inhalation, 2 puff BID

Guaifenesin 5ml solution, 10ml PO Q4H PRN

Levothyroxine 200mcg, PO QD

Home medications:

Albuterol-ipratropium 2.5 mg-0.5 mg/3 mL inhalation solution inhaled Q6H, PRN

Proair HFA 90mcg/inh inhalation, 2 puff QID

Symbicort 80mcg-4.5mcg/inh inhalation, 2 puff BID

Guaifenesin 5ml solution, 10ml PO Q4H PRN

Levothyroxine 200mcg, PO QD

Allergies:

Penicillin – anaphylaxis

Iodine – unknown reaction

Patient denies any foods or environmental allergies.

Family History:

Father- 80s, deceased, HTN, DM

Mother- 60s, deceased, obesity, breast cancer

Social History:

Mrs. C lives by herself in Queens after her husband passed away. Retired, used to be a violinist. Her sleep quality is fair, and she usually sleeps about 5 hours a day. No exercise and she has a large coffee every morning. Sexually inactive, no history of STDs. A former smoker, a quarter pack per day for 10 years, quitted 40 years ago. Denies recent travel, alcohol consumptions, past or present illicit drug use.

ROS:

General: Patient denies recent weight loss or weight gain, fatigue, loss of appetite, generalized weakness, fever, chill or night sweats

Skin, Hair, Nails: Patient denies any changes of texture, excessive dryness or sweating, discolorations, rashes

Head: Patient denies headache, vertigo, head trauma, or fracture

Eyes: Patient reports using glasses, and denies visual disturbance, lacrimation, pain, or pruritus

Ears: Patient denies deafness, pain, discharge, tinnitus

Nose/Sinuses: Patient denies discharge or obstruction

Mouth and throat: Patient denies bleeding gums, sore tongue, sore throat

Neck: Patient denies localized swelling or lumps, stiffness or decreased range of motion

Breast: Mastectomy 2017, denies lumps, pain

Pulmonary System: Patient reports mild SOB with greenish-yellow productive cough, denies hemoptysis, cyanosis, or orthopnea

Cardiovascular System: Patient reports chest soreness, and denies chest pain, palpitations, edema, syncope

Gastrointestinal System: Patient denies dysphagia, vomiting, nausea, abdominal pain, diarrhea, jaundice, hemorrhoids, constipation, blood in the stool

Genitourinary System: Patient denies nocturia, urgency, oliguria, polyuria, dysuria

Menstrual and Obstetrical: Patient last normal period is about 20 years ago, the time of menarche is 12 years old, the menstrual cycle was 30 days with the medium flow without clots. Patient denies postcoital bleeding, dyspareunia.

Nervous System: Patient denies headache, loss of consciousness, sensory disturbances, numbness, paresthesia, loss of strength, mental status, memory, or weakness

Musculoskeletal System: Patient denies deformity or swelling, or redness

Peripheral System: patient denies intermittent claudication, varicose veins

Hematological System: Patient denies anemia, easy bruising or bleeding

Endocrine System: Patient denies polyuria, polydipsia, polyphagia, heat or cold intolerance

Psychiatric: Patient denies depression or anxiety

Physical Examination:

General: 69 years old elderly female is alert and oriented x3, medium build, in patient’s gowns, lying in a stretcher, looks stated age, in no acute distress.

Vital Signs:

BP (lying): 111/63

HR: 75 BMP, regular

RR: 20, not labored

Temp: 96.4 F oral

O2 sat: 96% nasal cannula O2 flow 2L

Height: 5ft 9in Weight: 161lb BMI: 23.8, normal

Skin: Warm & moist, good turgor. A round chemo port at right upper chest. Two approximately 11cm well-healed surgical scars on anterior mid-chest bilaterally.

Hair: Average quantity and distribution

Nails: No clubbing, capillary refill <2 seconds throughout.

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

Eyes: PERRLA, EOMs full with no nystagmus, exophthalmos or ptosis; sclera white; conjunctiva & cornea clear. Visual acuity with glasses 20/20 OS, 20/20 OD, 20/20 OU. Visual fields full OU

Ears: Symmetrical and normal size. No lesions, masses, trauma on external ears. No discharge. TM’s pearly white, cone of light intact, a small amount of cerumen noted bilaterally

Nose: Symmetrical with no masses, lesions, deformities, or trauma

Throat: Pink, hydrated, no lesions, uvula light pink, no edema

Neck: Trachea midline. Supple nontender to palpation. No lymphadenopathy

Chest: Symmetrical, no deformities. Respirations unlabored. Nontender to palpation

Lungs: Rhonchi on the right side. No rales, no wheezing, breath sounds heard bilaterally

Heart: RRR, S1, S2 without murmur, no gallops

Abdomen: Flat, symmetrical. Bowel sounds in all 4 quadrants. Nontender, no guarding, no CVA tenderness bilaterally

Rectal: not exanimated

Female genitalia: not exanimated

Peripheral vascular: No cyanosis or edema bilaterally, 2+ pulses in upper and lower extremities

Neurological:

Mental status: Alert and oriented to person, place and time. Memory and attention intact. Thought coherent.

Cranial nerve:

I – not exanimated.

II- VA 20/20 bilaterally with glasses. Visual fields full.

III-IV-VI- pupils equal, round, and react to light, EOM intact without nystagmus.

V- Facial sensation intact.

VII- Symmetric facial movements, no weakness.

VIII- Hearing grossly intact to whispered voice bilaterally.

IX-X-XII- Swallowing and gag reflex intact. Tongue movement intact.

XI- Shoulder shrug intact. Sternocleidomastoid and trapezius muscle strong.

Motor/Cerebellar: Full active and passive ROM of all extremities

Sensory: Intact to light touch, sharp/dull

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

Musculoskeletal System: No soft tissue swelling, erythema, ecchymosis. Nontender to palpation, no crepitus noted throughout. Full range of motion.

Differential Diagnosis:

  • Pulmonary embolism: SOB, chest pain, cough, and decreased saturation 88%
  • Pneumonia: chronic productive cough, SOB, chest pain, rhonchi
  • Breast cancer metastatic to lungs: constant cough, SOB, pain in the chest
  • TB: a 1-month history of productive cough, chest pain

Labs:

UA: clear, PH 6.2, negative for glucose, protein, ketones, nitrite, leukocyte esterase

UA micro: RBC 1; WBC none; bacteria: negative

138 | 101 | 9.0

——————–< 130

4.0 |  25 | 0.73

 

12.9

8.0)——-(373, neutrophil: 68.1%; Lymphocyte 21.74%; Monocyte 6.8%

42

Troponin: <0.010 x 2 sets

Acid-fast bacillus negative x1

Imaging:

EKG: sinus rhythm at 78bmp, no ST elevations or depressions, no T wave inversions

CXR: small patchy/focal airspace opacity noted within the right upper lobe adjacent to the right upper hilum and right lower lobe

CT of chest w/o contrast: pneumonia in the right lower lobe; emphysema, pulmonary scar; trace pericardial thickening/effusion, decreased

TTE: normal LV, EF 60 to 65%, normal RV size and systolic function, mitral vales appears grossly normal, trace tricuspid regurgitation, no significant pericardial effusion

Assessment: A 69 years old female with past medical history of asthma on 2L home O2 (last hospitalized on June 2018), right breast cancer on chemo (last chemo treatment one month ago), and hypothyroidism c/o chest pain, diffused, soreness, “at times sharp” 5/10, no radiation. Patient sent to ED by her PCP due to chest pain and hypoxia of 88% saturation. Also, c/o chronic productive cough with greenish-yellow sputum for about 1 month and mild SOB. In ED, patient was given oxygen via nasal cannula, fentanyl IV push, and aspirin. On physical examination, rhonchi noted. Labs with troponin negative 2 sets; EKG with sinus rhythm; CXR showed opacity in the right lobe and CT of the chest showed RLL pneumonia. Current findings are most consistent with community-acquired pneumonia.

Plan:

  • Community-acquired pneumonia
  • Admit to medicine
  • Start on 2g ceftriaxone IV, and then change to azithromycin 500mg PO x 7days
  • Continue oxygen supplement 2L via nasal cannula, keep SpO2 >94% at all time
  • Repeat CBC, BMP
  • Follow up pulmonology
  • Infectious disease consults and follows up with recommendations
  • R/o ACS
  • Admit to medicine with tele
  • HR on admission 75bpm, SpO2 96% on 2L nasal cannula
  • EKG, TTE negative
  • Troponin negative x2 sets, trend one more
  • Follow up cardiology if needed
  • Breast cancer
  • Last chemo session last month, when stable, will continue chemo
  • Follow up with urine culture and blood culture
  • Asthma
  • SpO2 96% on 2L nasal cannula
  • Continue home medication, Albuterol-ipratropium 2.5 mg-0.5 mg/3 mL inhalation solution inhaled Q6H, PRN; Proair HFA 90mcg/inh inhalation, 2 puff QID; Symbicort 80mcg-4.5mcg/inh inhalation, 2 puff BID
  • Follow up with pulmonary
  • Hypothyroidism
  • Continue home medication, Levothyroxine 200mcg, PO QD
  • Follow up TSH
  • Diet
  • Regular cardiac diet

 Follow up appointments

  • Patient need follow up appointment with PCP within 1 week after anticipated discharge if not appointment already scheduled
  • Repeat CXR in weeks after symptoms have resolved

Patient education:

Mrs. K, based on the signs and symptoms you have, like chest pain, cough with sputum, shortness of breath, and rhonchi I heard from lungs, you most likely have pneumonia. Pneumonia is an infection that inflames the air sacs in one or both lungs. The air sacs may fill with fluid or pus, causing a cough with phlegm and difficulty breathing. We will continue oxygen therapy, and add antibiotics to your current regimen. So, we are going to keep you here, in the hospital, for observation, and to better monitor your chest pain, breathing, and cough. A pulmonologist and a doctor from the infectious disease will come to see you later, who will let us know if we need to adjust any medications for you. I know that you get chemotherapy for breast cancer, and we will contact your oncology doctor and figure out the chemo schedule and will continue your chemo after you are more stable. For your asthma and thyroid problems, we will continue your medications you taking at home. If your symptoms, like shortness of breath and cough, get worse, or any new symptoms, like fever, feel chest pain, do not hesitate to call the nurse right away, we will come and help. There the plan, for now, do you have any questions for me?

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