Full H & P 2 – IM

Identifying Data:

Full Name: Mrs. C. P.

DOB (Age):  75 YO

Gender: Female

Date & Time: Feb. 26, 2020 / 8:00 AM

Location: QHC-IM, Queens, NY

Source of information: Self

Reliability: Reliable

Chief Complain:  “My eyes are blurry” X 30 mins

HPI:

75 Y.O. Hispanic female with PMH of HTN, HLD, T2DM, GERD, admitted yesterday c/o blurry eyes for 30 minutes. Pt visited her primary doctor yesterday morning for regular checkup. During that time, she felt blurry of both eyes suddenly. Then her PCP sent her to the ED since the systolic pressure was noted higher than 200 mmHg. Stated that she was asymptomatic other than blurry vision before arriving at ED. However, she started to have pressure like feeling in the mid chest and headache after hydralazine drip at ED. She described the headache was felt more like “squeezing”, rate as 5/10, around the frontal area and radiated to the both eye lids. Nothing made the pain worse. But it was relieved by Tylenol. After the CT head was done in ED, she was transferred to the floor for monitoring. The BP at admission yesterday was 205/104, and now was 153/84 this morning. Currently, she stated that the headache was improved, but still felt mild pain on the left side of the frontal area and radiated down to the neck with rate 1/10. She stated that she took all of her antihypertensive daily, last dose is yesterday morning, but did not take her Lasix due to run out of the pills. Denies fever, chills, SOB, cough, chest pain, palpitation, dysuria, dizziness, or head injury.

Past Medical History:

• Present illnesses –HTN & HLD x 20 years; T2DM x 15 years; GERD x 9 years.
• Past medical illness –cataract (2018)
• Childhood illnesses – None
• Immunization – Up to date; last flu vaccine yearly.
• Screening tests and results – pap-smear: unknown

Past Surgical History:

• Hysterectomy – 2006
• Wrist fracture Surgery – 1997

Home Medications:

• Aspirin 81 mg PO daily for CVD prevention
• Atenolol 25 mg PO daily for HTN
• Furosemide 40 mg PO Q6H for fluid retention (edema)
• Glimepiride 1 mg PO daily for T2DM
• Metformin 500 mg PO daily for T2DM
• Pantoprazole 20 mg PO daily for GERD
• Vitamin D 2000 units PO daily for daily supplement

Allergies:

• Pt has no known allergies

Family history:

• Mother – Deceased at age 71, from colon cancer
• Father – Deceased at age 70s, from stomach cancer
• Sister – Deceased at age 29, from Lupus
• Daughter – 40s, alive and healthy
• Son– 40s, alive with HTN

Social History:

Mrs. R is a widowed, living with her son in a private house; retired. Two children.

Habits –denies the history of smoking, alcohol use, or illicit drug use.

Travel – Denies traveling recently.

Diet – Regular diet.

Exercise – she walks about 2 hour per week in her community neighborhood.

Sleep – She sleep well and average 6 hours per day.

Review of systems:

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

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.

• Positive: Mild pain on the left side of the frontal area.

Eyes –Denies diplopia, fatigue with use of eyes, scotoma, halos, lacrimation, photophobia, pruritus. Last eye exam: none.

• Positive: blurring vision yesterday morning, resolved now

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 Dec, 2019.

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

Breast – Denies lumps, nipple discharge, or pain.

Pulmonary system – Denies wheezing, dyspnea, cough, hemoptysis, cyanosis, orthopnea, or paroxysmal nocturnal dyspnea (PND).

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, diarrhea, jaundice, hemorrhoids, constipation, rectal bleeding, or blood in stool.

• Positive: epigastric pain, resolved by PPI meds

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

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

Menstrual/Obstetrical – G2P2. Menarche age 11.

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

Musculoskeletal system –Denies muscle pain, or deformity.

• Positive: Mild pain on the left side of neck due to radiation from the left frontal headache.

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 polyuria, polydipsia, polyphagia, heat or cold intolerance, excessive sweating, hirsutism, or goiter.

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

Differential Diagnosis:

HTN urgency

Pseudotumor cerebri

Migraine

Temporal arteritis

Stroke

Physical Examination:

Vital Signs:

BP:  L 153/84, R 157/88, Seated

RR: 18 breaths/min, Unlabored

P: 76 beats/min, Tachycardia

T: 98.4 F, oral

O2 Sat: 99% room air

Ht: 65 inches

Wt: 181lbs.

BMI: 30.1 obese

General: Patient is a 75 year old female, 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, except left frontal area. no trauma, no specific facies.

• Positive: mild pain on the left frontal area to palpation

Eye: Symmetrical OU; no strabismus, exophthalmos or ptosis; sclera white; conjunctiva & cornea clear. Visual fields full OU. PERRL, EOMs full with no nystagmus.

Ears: Symmetrical, no evidence of mass, lesion, erythema, inflammation, ear canal atresia. Non tender to palpation. Auditory Acuity: whisper test, intact to whispered voice AU.

Nose/Sinuses:

Nose – Symmetrical, no evidence of mass, lesion, deformities, erythema, inflammation. Non-tender to palpation and no step-off. no evidence of nasal obstruction

Sinuses – Non tender to palpation

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 – Clear to auscultation. No adventitious sounds. No stridor, respiratory distress.

Cardiovascular:

Regular rate and rhythm (RRR); S1, S2 noted; No gallops, S3 or S4. 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.

Breast/Female Genitalia/Rectal: Patient refused the exams.

Peripheral Vascular System: 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- Visual fields by confrontation full.
• III-IV-VI- PERRL, 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.
• IX-X-XII- Swallowing and gag reflex intact. Uvula elevates midline. Tongue movement intact.
• XI- Shoulder shrug intact.

Motor/Cerebellar: Full active/passive ROM of B/L upper and lower extremities without rigidity or spasticity. Normal muscle bulk and tone. No atrophy, tics, tremors or fasciculations. Strength equal and appropriate for age bilaterally (5/5 throughout). Coordination-finger to nose intact. Normal gait.

Sensory: For b/l upper and lower extremity, Intact to light touch, sharp/dull, point localization, extinction.

Reflexes

• Patellar : R-2+ ; L-2+

Meningeal Signs: No nuchal rigidity noted. Brudzinski’s and Kernig’s signs are 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.  No evidence of spinal deformities.

Labs:

• CBC: WBC/HGB/HCT/PLT: 24 / 9.7↓/ 32.0 ↓ / 331
• CHEM/LYTES- Na/K/CL/CO2/BUN/Cr/Glu/Ca– 138/ 4.4 /102/ 27 /16 /0.85/88/6 ↑
• LFT: alb/TP/TBiL,DBil/ALKP/ALT/AST:3.5/6.8/<0.3/85/20/22

Imaging:

• CT Head without contrast:
  • Impression – extra-axial somewhat broad-based hyperdense/calvarium bordering the anterior falx as described above likely representing a meningioma with mild mass effect and no significant surrounding vasogenic edema.

Assessment and Plan:

Mrs. R. is a 75 YO female with PMH of of HTN, HLD, T2DM, GERD, presenting to ED from PCP due to elevated SBP above 200 mmHg and c/o blurry eyes for 30 minutes. Lab showed Na 138, K 4.4, Ca 10.6, BUN/Cr 0.85/16, Hb 9.7. CT head shows hyperdense lesion located on the anterior falx likely representing a meningioma without no significant surrounding vasogenic edema.

Hypertensive urgency:

• Tylenol 325 mg PRN for headache possible due to BP drop
• Start Hydralazine 10 mg Q6H for HTN
• Start Losartan 100 mg QD for HTN
• Resume Atenolol 25 QD for HTN

Type 2 diabetes mellitus

• Resume Glimepiride 1 mg PO daily
• Resume Metformin 500 mg PO daily

HLD

• Resume Lipitor 40 mg

Meningioma

• Neuro recs appreciated
• Outpatient MRI with and without contrast ordered
• Seizure precaution

GERD

• Continue Pantoprazole