Full H & P  – LCT

Identifying Data:

Full Name: Mr. S. R.

DOB (Age):  xx/xx/1946 (74)

Gender: Male

Date & Time: Jan. 24, 2020 / 10:00 AM

Location: VA, Jamaica, NY

Source of information: Self

Reliability: Reliable

Source of Referral: N/A

Chief Complain:  “I have a bad cough” X 5 days

HPI:

74 year old Caucasian male with PMH obesity, HTN, hyperlipidemia, T2DM, COPD, and former smoker, admitted to St. Albans on 11/11/2019 for long term care. Pt was seen today due to c/o productive cough for five days. The sputum is thick and yellowish. He also complains an intermittent short of breath. Resident developed a fever, chills and malaise along with the cough two days ago. One day ago he developed pain in his right chest with inspiration. Past history reveals that he had a chronic cough for 10 years which he describes as being mild, non-productive and occurring most often in the early morning. He currently is a non-smoker but did smoke a pack a day for approximately 15 years prior to quitting five years ago. Denies lose appetite, weight lose, N/V/D, HA, sweating, and fainting. Denies chest tightness, squeezing, heaviness, or a crushing sensation.

Past history reveals that he was living at home with wife in second floor walk up. Due to obesity, much of his day was spent in bed watch TV. He presented to NYVA – ER from home on 11/09/2019 with c/o left chest pain after fall which happened 4 days ago. He states that he was fell to the floor when while alone he attempted to use bedside commode. Denies unconscious, hit his head or lost control of bowel or bladder.  He also reports an atraumatic fall while being transferred with help of family two weeks prior to this incident.  He was brought to NYVA – ER by family members four days after fall. He reports left chest pain without radiation; the pain was rated as 5/10; and usually relieved with tylenol. Work-up was done in ER. Chest X-ray negative for rib fracture. CT of cervical spine and head negative for hemorrhage or fracture.  Bilateral lower extremity duplex is negative for DVT. He was diagnosed with musculoskeletal disorders. The pain was reduced to 0/10 after acetaminophen 325mg was given. He is being transferred to St. Albans on 11/11/2019 with hemodynamically stable for long stay maintenance due to his family no longer able to manage him at home.

Past Medical History:

Present illnesses –HTN & HLD x 20 years; T2DM x 10 years; COPD x 15 years

Past medical illness – Gallbladder stone (1990)

Hospitalizations – Shock Wave Lithotripsy, 1990 (unable to recall hospital and surgeon name)

Childhood illnesses – asthma (unable to recall the age)

Immunization – Report having Measles, mumps, chickenpox, and pneumococcal vaccination; last flu vaccine yearly.

Past Surgical History:

Shock Wave Lithotripsy – 1990

Medications:

• Cefepime 2 g IV Q8H x 7 days for suspected Pneumonia
• Dextromethorphan 20 mg PO Q6H for cough
• Tiotropium 1 capsule (18 mcg) inhaled daily using HandiHaler device for COPD
• Albuterol 90mcg 2 PUFFS INHL,ORAL Q4H PRN for SOB
• Budesonide 160 mcg/formoterol 4.5 mcg 2 Puffs INHL, ORAL Q12H for COPD
• Metformin 500 mg PO daily for T2DM
• Amlodipine Besylate 10mg PO daily for HTN
• Lisinopril TAB 5mg PO daily for HTN
• Atorvastatin Calcium TAB 40mg PO QHS for Hyperlipidemia

Allergies:

NKDA

Family history:

Mother – Deceased at age 79, unknown cause

Father – Deceased at age 72, from COPD

Son – 40s, alive and well

Daughter – 40s, alive and well

Younger sister – 60s, alive and well

Social History:

Mr. C. C. is a marine corp x 6 years, Vietnam; retired correction officer. Married. Two children.

Living: Prior to admission, patient reports living at home with wife in second floor walk up.

Habits –smoke a pack a day for approximately 15 years prior to quitting five years ago; Denies alcohol/bear, or illicit drug use.

Travel – He denies traveling recently.

Diet – Regular diet, but frequently intake high sugar snack, like cookies, ice cream, chocolate.

Sleep:  Denies sleeping problem; average 6 hours each day.

Review of systems:

General –No appreciable disease.  Patient denies recent weight loss or weight gain, loss of appetite, or night sweats

• Positive: lying in bed. Obesity. Patient reports fever, chill for past 3 days

Skin, hair, nails – Denies changes in texture, excessive dryness or sweating, discolorations, pigmentations, or changes in hair distribution.

Head – Denies headaches, vertigo, head trauma, unconsciousness, coma, or fracture.

Eyes – states use glasses for reading. Denies visual disturbance, like blurring, diplopia, fatigue with use of eyes, scotoma, halos, lacrimation, photophobia, pruritus. Last eye exam on March, 2019.

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

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

Mouth and throat – Denies bleeding gums, sore tongue, sore throat, mouth ulcers, voice changes or use dentures. Last dental exam on July, 2019.

Neck – Denies localized swelling/lumps or stiffness/decreased range of motion.

Breast – Denies lumps, nipple discharge, or pain.

Pulmonary system – States h/o COPD, currently stable by meds. Denies hemoptysis, cyanosis, orthopnea, or paroxysmal nocturnal dyspnea (PND).

• Positive: states wet cough with yellowish sputum for 5 days; intermittent SOB; right chest pain with inspiration

Cardiovascular system – States h/o HTN, hyperlipidemia, currently stable by meds. Denies chest pain, palpitation, irregular heartbeat, edema/swelling of ankles or feet, syncope or known heart murmur.

Gastrointestinal system – Regular bowel movements daily. Denies nausea, loss appetites, intolerance to specific foods, dysphagia, pyrosis, unusual flatulence or eructations, abdominal pain, diarrhea, jaundice, hemorrhoids, constipation, rectal bleeding, or blood in stool.

Genitourinary system – states urinary frequency. Denies polyuria, nocturia, oliguria, dysura, incontinence, awakening at night to urinate or flank pain.

-Male ONLY: Denies hesitancy, dribbling or last prostate exam

-Sexual History: States he is currently sexually inactive. Denies STI or contraception.

Nervous system – Denies seizures, loss of consciousness, sensory disturbances, ataxia, loss of strength, or change in cognition/mental status/memory.

Musculoskeletal system – Denies joint deformity or swelling, or redness.

Peripheral vascular system – denies intermittent claudication, coldness or trophic changes, varicose veins.

Hematologic system – denies transfusion, easy bruising or bleeding, lymph node enlargement or history of DVT/PE

Endocrine system – Denies polyruria, polydipsia, polyphagia, heat or cold intolerance, excessive sweating, hirsutism, or goiter.

Psychiatric – Denies depression, sadness, anxiety, obsessive, or any experience of seen mental health professional.

Physical Examination:

Vital Signs:

BP:

L 138/87, R 134/84, Seated

L 132/81, R 139/86, Supine

RR: 18 breaths/min, Unlabored

P: 105 beats/min, Tachycardia

T: 101.9 F, oral

O2 Sat: 99% room air

Ht: 73 inches

Wt: 278lbs.

BMI: 36.7 obese

General – Patient is a 74 year old male, A& O x 3. Well developed and good posture. Well dressed, groomed and nourished. No apparent distress.

Skin – warm & dry, good turgor. No scar, increase or loss in pigmentation, nonicteric

Nail – no clubbing. Capillary refill < 2 seconds throughout. Nails are trim

Hair – average quantity and soft of hair, evenly distribution, no signs of lice, nits, no seborrhea.

Head – eyes and ears aligned, normocephalic, atraumatic, non tender to palpation throughout, no trauma, no specific facies.

Eye: Symmetrical OU; no strabismus, 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. PERRLA (old people do not accommodate), EOMs full with no nystagmus. Fundoscopy – Red reflex intact OU. Cup:Disk < 0.5 OU, no AV nicking, papilledema, hemorrhage, exudate, cotton wool spots, or neovascularization OU

Ears: Symmetrical and normal size.  No evidence of lesions, masses, trauma on external ears.  No discharge, foreign bodies in external auditory canals AU. TM’s pearly white, intact with light reflex in normal position AU.

Nose/Sinues:

Nose – Symmetrical, no obvious masses, lesions, deformities, trauma, discharge. Nares patent bilaterally. Nasal mucosa pink and well hydrated. No discharge noted on anterior rhinoscopy.  Septum midline without lesions, deformities, injection, perforation. No evidence of foreign bodies.

Sinuses – Non tender to palpation and percussion over bilateral frontal, ethmoid and maxillary sinuses.

Mouth/Throat:

Pink and well hydrated lip, gingivae, tongue, mucosa, and palate. No masses, lesions, erythema, exudate or discharge noted. Good dentition. No obvious dental caries noted. Non-tender to palpation. Uvula pink, no edema, deviation.

Neck/Thyroid:

Trachea midline. 2+ Carotid pulses. No masses, lesions, scars, pulsations noted. No stridor, thrills, bruits noted bilaterally. No palpable adenopathy noted. Non-tender to palpation, no thyromegaly noted.

Thorax and Lungs:

Chest – Symmetrical, no deformities, no evidence trauma.   Respirations unlabored, no paradoxic respirations or use of accessory muscles noted.  Lat to AP diameter 2:1.  Non-tender to palpation.

Lungs – Both lungs are resonant by percussion, except the right middle lobe is dull. Auscultation reveals B/L diminished breath sounds. Late inspiratory crackles heard in the area of the right middle lobe. The remainder of the lung fields is clear.

Cardiovascular:

S1, S2 without murmur, no gallops, S3 or S4. RRR. No JVD. Carotid pulse 2+ bilaterally without bruits.

Abdomen:

Obese, symmetrical, no evidence of scars, striae, caput medusae or abnormal pulsations. BS present in all 4 quadrants. No bruits noted over aortic/renal/iliac/femoral arteries. Tympany to percussion throughout. Non-tender to percussion or to light/deep palpation. No evidence of organomegaly. No masses noted. No evidence of guarding or rebound tenderness. No CVAT noted bilaterally.

Male Genitalia: Circumcised male. No penile discharge or lesions. No scrotal swelling or discoloration. Testes Descended bilaterally, smooth and without masses. Epididymis nontender. No inguinal or femoral hernias noted

Anus, rectum, and prostate: No perirectal lesions or fissures. External sphincter tone intact. Rectal vault without masses. Prostate smooth and nontender with palpable median sulcus. Stool brown and Hemoccult negative

Peripheral Vascular Systerm: Skin normal in color and warm to touch upper and lower extremities bilaterally.  No calf tenderness bilaterally. No palpable cords or varicose veins 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

I – Intact no anosmia.

II- VA 20/20 bilaterally. Visual fields by confrontation full. Fundoscopic + red light reflex OS/OD, discs yellow with sharp margins. No AV nicking, hemorrhages or papilledema noted.III-IV-VI- PERRLA, EOM intact without nystagmus.

V- Facial sensation intact, strength good.

VII- Facial movements symmetrical and without weakness.

VIII- Hearing grossly intact to whispered voice bilaterally. Weber midline. Rinne AC>BC.

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

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

Motor/Cerebellar: Normal muscle bulk and tone. No atrophy, tics, tremors or fasciculations.

• Positive: slow gait, slightly unsteady assisted with walker

Sensory: Intact to light touch, sharp/dull, vibratory, proprioception, point localization, extinction, stereognosis and graphesthesia testing bilaterally.

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. Brudzinski’s and Kernig’s signs negative.

Musculoskeletal: No erythema / ecchymosis / atrophy / or deformities in bilateral upper and lower extremities. No crepitus noted throughout. No evidence of spinal deformities. FROM of all upper and lower extremities bilaterally.  No evidence of spinal deformities.

Assessment and Plan:

74 year old Caucasian male with PMH obesity, HTN, hyperlipidemia, T2DM, COPD, and former smoker, presented to NYVA – ER on 11/09/2019 with c/o left chest pain after fall. After the pain was controlled, he was transferred to St. Albans on 11/11/2019 for long stay maintenance since family no longer able to manage resident at home. Currently, resident c/o productive cough with fever for five days.

Pneumonia: highly suspect due to history of cough, dyspnea, pleuritic pain, with abnormal vital signs such as fever and tachycardia; and abnormal lung examination findings like right middle lobe is dull to percussion, B/L diminished vesicular breath sounds to auscultation, and late inspiratory crackles heard in the area of the right middle lobe. Need chest radiography to verify.

• Chest X-ray was ordered
• Lab:
  • CBC with differential was ordered
  • Sputum for Gram stain
• Cefepime 2 g IV Q8H for 7 days
• Dextromethorphan 20 mg PO Q6H
• Encourage coughing to eliminate sputum
• Continue to monitor

Fall prevention:

• Resident was instructed to use the call button when he needs help especially when transferring from bed to wheelchair
• Maintain fall safety/fall precautions
• Continue to monitor

COPD: Stable currently

• Continue Tiotropium 1 capsule (18 mcg) inhaled daily using HandiHaler device
• Albuterol 90mcg 2 PUFFS INHL,ORAL Q4H PRN for SOB
• Continue Budesonide 160 mcg/formoterol 4.5 mcg 2 Puffs INHL, ORAL Q12H
• Monitor for SOB, desaturation, and exacerbation
• Keep up to date with influenza vaccine

T2DM: Last HgbA1c 8.3% on 01/02/2020

• Continue Metformin 500 mg PO daily
• Continue to monitor blood sugar

HTN: stable currently

• Continue Amlodipine Besylate 10mg PO daily
• Continue Lisinopril TAB 5mg PO daily
• f/u lab including CBC, CMP, lipids
• Continue to monitor BP

Hyperlipidemia: Last Total cholesterol/Triglycerides/HDL/HDL – 235/263/49/141mg/dL on 01/02/2020

• Atorvastatin Calcium TAB 40mg PO QHS
• f/u lipid panel
• Continue to monitor

Weight loss

• Continue 2000 calorie controlled diet
• Consult with nutrition was ordered

Differential Diagnosis:

Pneumonia

Viral infection

COPD exacerbation

Lung cancer