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?