HISTORY: 

Identifying data:

Date & Time: November 22, 2023 10:00 AM

Full name: Ms. R.L

Address: Flushing, NY

Date of birth: 11/08/1946

Location: NYPQ, Flushing, NY

Religion: Christian

Marital status: Single

Source of information: Self

Reliability: Reliable

Source of referral: PCP

Mode of transport: Patient was brought in via car by uber.

Chief Complaint:

“Short of breath” x 3 days

History of Present Illness: 

77 y/o female with PMH of HFrEF, left breast mastectomy and well controlled HTN, brought to the ED yesterday c/o dyspnea that began 3 days prior to arrival. Patient states the dyspnea has worsened over the course of 3 days and states having to catch her breath after walking down one block. Reports the severity of dyspnea as 2/10 at rest and 8/10 with exertion.Pt states she had traveled in the previous week ,5 hour bus ride to boston.Pt also states mild chest pain that is associated with her dyspnea for the past 3 days.Pt states pain in her left chest that does not radiate to other parts of her body.Pt describes the pain as tightness and states it gets worse when she takes in a deep breath. Reports pain is currently 3/10 and has only taken tylenol for the pain with no relief.Denies palpitations, cough, fever, fatigue, syncope, wheezing, nausea, vomiting, fatigue, personal or family hx MI.

Past Medical History: 

• Hypertension x 15 years, well controlled on medications
• Heart failure with reduced ejection fraction x 3 years
• Immunizations: up to date; Covid vaccines and booster up to date (unknown dates); Flu vaccine received(unknown date)

Past Surgical History:

• Left Breast Mastectomy – 1998
• Denies past injuries or blood transfusions.

Medications:

• Metoprolol, unknown dosage, for hypertension & heart failure, last dose today
• Furosemide, unknown dosage, for hypertension & heart failure, last dose today
• Denies use of herbal supplements.

Allergies:

• NKDA, no food or environmental allergies.

Family History: 

• Mother – Deceased at age 88, natural causes, hx of HTN.
• Father – Deceased at age 68, natural causes, hx of HTN, HF

Social History:

• Habits – Denies caffeine use. Nonsmoker, denies alcohol or drug use.
• Travel – 5 hour bus ride to Boston, last week tuesday
• Marital history – Single
• Occupational history –  Retired librarian
• Home situation – Lives alone in an apartment in Queens, NY.
• Diet – Admits to a diet consisting of Sleep patterns – Admits to average sleep pattern (7-8 hrs day)
• Exercise – Denies being physically active.
• Safety measures – Admits to seat belt use.

Review of Systems:

• General: Denies generalized weakness/fatigue, fever, chills, night sweats, weight loss or gain, changes in appetite.
• Skin, hair, nails: Denies changes in texture, excessive dryness or sweating, discolorations, pigmentations, moles/rashes, pruritus, changes in hair distribution.
• Head: Denies headaches, head trauma, vertigo.
• Eyes: Last eye exam 6 months ago. Unknown visual acuity. Denies lacrimation, pruritus, visual disturbances, photophobia.
• Ears: Denies deafness, pain, discharge, tinnitus, hearing aid use.
• Nose: Denies discharge, obstruction, epistaxis.
• Mouth/throat: Last dental exam about 2 months ago. Denies voice changes, bleeding gums, sore tongue, sore throat, mouth ulcers, dentures use.
• Neck: Denies localized swelling/lumps, stiffness/decreased ROM
• Breast: Denies lumps, nipple discharge, pain.
• Pulmonary: Admits to dyspnea, dyspnea on exertion. Denies cough, wheezing, cyanosis, hemoptysis,orthopnea, paroxysmal nocturnal dyspnea
• Cardiovascular: Admits to chest tightness,irregular heartbeat on auscultation, hx of HTN, visits cardiologist regularly for heart failure management. Denies , palpitations , syncope, known heart murmur.
• Gastrointestinal: Has regular bowel movements daily. Last colonoscopy exam was 2 years ago. Denies change in appetite, intolerance to specific foods, nausea, vomiting, dysphagia, pyrosis, unusual flatulence or eructations, abdominal pain, diarrhea, jaundice, hemorrhoids, constipation, rectal bleeding, or blood in stool.
• Genitourinary: Denies urinary frequency, urinary urgency, nocturia, oliguria, polyuria, dysuria, incontinence, flank pain, hematuria, history of hernias.
• Menstrual/Obstetrical: Denies urinary frequency, urinary urgency, nocturia, oliguria, polyuria, dysuria, incontinence, flank pain, hematuria, history of hernias.
• Sexual History: Denies being sexually active in over 10 years. Denies history of STIs.
• Musculoskeletal: Denies arthritis, muscle pain, deformity or swelling, redness.
• Nervous system: Denies seizures, headache, loss of consciousness, sensory disturbances, ataxia, loss of strength, change in cognition/mental status/memory.
• Peripheral vascular: Admits to B/L leg peripheral edema. Denies intermittent claudication, varicose veins, coldness or trophic changes, color changes.
• Hematologic: Denies anemia, easy bruising or bleeding, lymph node enlargement, blood transfusions, history of DVT/PE.
• Endocrine: Denies polyuria, polydipsia, polyphagia, heat or cold intolerance, excessive sweating, goiter, hirsutism.
• Psychiatric:  Denies depression/sadness, anxiety, OCD, or ever seeing a mental health professional.

PHYSICAL: 

General: Overweight female, neatly groomed, appears her stated age of 77.

Vital Signs:

BP:              R                             L

Seated         102/73                104/73

Supine         106/74                     102/72

R: 25/min, unlabored                      P: 115 beats/min, regular

T: 98.1 degrees F (oral)                  O2 Sat: 95% 3L nasal Cannula

Height: 65in    Weight: 165 lbs      BMI: 27.5

Skin: Warm & moist, good turgor. Nonicteric, no lesions noted, no scars, no tattoos.

Hair: Short, white hair, average quantity and distribution.

Nails: No clubbing, capillary refill < 2 seconds in upper and lower extremities.

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

Ears: Symmetrical and appropriate in size. No lesions, masses or trauma on external ears. No discharge or foreign bodies on external auditory canals AU. TM pearly grey and intact with light reflect in good position AU. Auditory acuity intact to whispered voice AU. Weber midline. Rinne reveals AC > BC AU.

Nose: Symmetrical. No masses, lesions, deformities, trauma or discharge. Nares patent bilaterally, nasal mucosa pink & well hydrated. No discharge noted on anterior rhinoscopy. Septum midline without lesions, deformities, injection or perforation. No foreign bodies.

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

Mouth/Pharynx-

Lips: Pink, moist, no cyanosis or lesions.

Mucosa: Pink, well hydrated. No masses or lesions noted. No leukoplakia.

Palate: Pink, well hydrated. Palate intact with no lesions, masses, scars.

Teeth: Good dentition, no obvious dental caries noted.

Gingivae: Pink, moist. No hyperplasia, masses, lesions, erythema, or discharge.

Tongue: Pink, well hydrated. No masses, lesions or deviation.

Oropharynx: Well hydrated. No injection, exudates, masses, lesions or foreign bodies. Tonsils grade 2 present with no injection or exudate. Uvula pink, no edema or lesions.

Neck: Trachea midline. No masses, lesions, scars, or pulsations noted. Supple; non-tender to

palpation. FROM; no stridor noted. 2+ Carotid pulses, no thrills; bruits noted bilaterally, no cervical adenopathy noted.

Thyroid: Non-tender; no palpable masses; no thyromegaly; no bruits noted.

Eyes: Symmetrical OU. No strabismus, exophthalmos or ptosis.  Sclera white, cornea clear, conjunctiva pink.
Visual acuity uncorrected – 20/25 OS, 20/25 OD, 20/25 OU
Visual fields full OU. PERRLA. EOMs intact with no nystagmus
Fundoscopy – Red reflex intact OU. Cup to disk ratio < 0.5 OU. No AV nicking, hemorrhages, exudates or neovascularization OU.

Cardiac: JVP is 3 cm above the sternal angle with the head of the bed at 30°. PMI in 5th ICS in mid-clavicular line. Carotid pulses are 2+ bilaterally without bruits.Irregular rate and rhythm. S1 and S2 are distinct with no murmurs, S3 or S4. No splitting of S2 or friction rubs appreciated.

Chest: Symmetrical, no deformities, no trauma.  Respirations unlabored(3L nasal Canula) / no paradoxic respirations or use of accessory muscles noted. Lat to AP diameter 2:1. Non-tender to palpation throughout.

Lungs: Diminished breath sounds in left lower lobe on auscultation. Chest expansion and diaphragmatic excursion symmetrical. Tactile fremitus symmetric throughout.

Abdomen: Abdomen flat and symmetric with no striae or pulsations noted. Bowel sounds normoactive in all four quadrants with no aortic/renal/iliac or femoral bruits. Non-tender to palpation and tympanic throughout, no guarding or rebound noted. No hepatosplenomegaly to palpation, no CVA tenderness appreciated.

Breast: Symmetric, no dimpling, no masses to palpation, nipples symmetric without discharge or lesions. No axillary nodes palpable.

Female Genitalia: External genitalia without erythema or lesions. Vaginal mucosa pink without inflammation, erythema or discharge. Cervix parous (or multiparous), pink, and without lesions or discharge. No cervical motion tenderness. Uterus anterior, midline, smooth, non-tender and not enlarged. No adnexal tenderness or masses noted. No inguinal adenopathy.

Rectal: Rectovaginal wall intact. No external hemorrhoids, skin tags, ulcers, sinus tracts, anal fissures, inflammation or excoriations. Good anal sphincter tone. No masses or tenderness. Trace brown stool present in vault. FOB negative.

Cranial Nerves: CN I- X11 are intact

Peripheral Neurologic Exam

Motor/Cerebellar – Full active/passive ROM of all extremities without rigidity or spasticity. Symmetric muscle bulk with good tone. No atrophy, tics, tremors or fasciculation. Strength 5/5 throughout.  Rhomberg negative, no pronator drift noted. Gait steady with no ataxia. Tandem walking and hopping show balance intact. Coordination by rapid alternating movement and point to point intact bilaterally, no asterixis

Sensory – Intact to light touch, sharp/dull, and vibratory sense throughout.   Proprioception, point localization, extinction, stereognosis, and graphesthesia intact bilaterally

Reflexes – 2+ throughout, negative Babinski, no clonus appreciated

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

Mental status exam: Patient is well appearing, good hygiene and neatly groomed. Patient is alert and oriented to name, date, time and location. Speech and language ability intact, with normal quantity, fluency, and articulation. Patient denies changes to mood. Conversation progresses logically. Insight, judgement, cognition, memory and attention intact.

Peripheral Vascular: 2+ pitting edema notes B/L. The extremities are normal in color and temperature. Pulses are 2+ bilaterally in lower extremities. No bruits noted. No clubbing, cyanosis. No stasis changes or ulcerations noted. No calf tenderness bilaterally, equal in circumference. Homan’s sign not present bilaterally. No palpable cords or varicose veins bilaterally. No palpable inguinal or epitrochlear adenopathy.

Musculoskeletal: No erythema / ecchymosis / atrophy / or deformities in bilateral upper and lower extremities. Non-tender to palpation / no crepitus noted throughout. FROM (Full Range of Motion) of all upper and lower extremities bilaterally.  No evidence of spinal deformities.

Differential Diagnosis:

• Pulmonary Embolism – patients have risk factors. Also has lower extremity swelling. Patient also stated recent immobilization during recent travel 
• CHF exacerbation – pt has risk factors (hx of HF, HTN,).
• New onset Afib- Pt PE and EKG show an irregularly irregular pattern.
• Pneumonia – patient has risk factors and worsening SOB.Also has pleuritic chest pain, denies any systemic symptoms so lower on ddx. 
• Pneumothorax – c/o dyspnea and has diminished breath sounds in the left lower lobe. Less likely due to a more gradual onset of SOB.

Assessment:

77 y/o female is in the ER currently waiting to be transferred to IM and further consultation.

• Place pt on cardiac and pulse ox monitoring
• Continue current meds & increase dosage of furosemide, administer oxygen to help with dyspnea, 
• Calculate Wells Criteria score +/- PERC score for risk of PE
• Chest Xray – to look for signs of cardiomegaly, r/o pneumonia or pneumothorax

(All the above were done in ER)

• Admit pt to floor and cardiology consult