LTC HPI 1

Chief Complaint: “Chest burning ” x 4 weeks

 History of Present Illness:

82 y/o female with a past medical history of HTN,hyperlipidemia, GERD and psychiatric history of anxiety disorder comes in today due to heartburn symptoms which have been worsening for 4 weeks. Patient states last visit she was diagnosed with GERD and started on Pepcid twice daily for her symptoms. Patient states no relief of symptoms with Pepcid. Patient states symptoms of pyrexia and acid reflux typically after her meals and worse when lying down before going to bed. Patient reports discomfort as a “burning sensation” that typically lasts about 5 seconds. Patient denies anything that helps relieve her symptoms, states she tries to drink a glass of cold water with no benefit. Patient denies any radiating pain. Patient denies any abdominal pain, nausea/vomiting, diarrhea or constipation or excessive NSAID use. 

Geriatric Assessment

  • ADLs: Independent in all
  • IADLs: Independent in all
  • Home Health Aide: None
  • Visual impairment: Yes – patient wears glasses
  • Hearing impairment: None
  • Falls in the past year: None
  • Assistive devices used: None
  • Gait impairment: None
  • Urinary incontinence: None
  • Fecal incontinence: None
  • Osteoporosis: None
  • Cognitive Impairment: None – Mini-cog: 5/5
  • Depression: None – PHQ 9 completed, score 7/27
  • Home safety issues: None
  • Health Care Proxy: Niece 
  • Advance Directives: Full code

Past Medical History

Medical History:

  • HTN
  • Hyperlipidemia
  • GERD
  • History of breast cancer
  • Anxiety 

Medications:

  • Losartan(Cozaar) 50mg tablet PO daily
  • Atenolol(Tenormin) 25mg tablet PO daily
  • Famotidine(Pepcid) 20 mg 1 tablet, two times a day
  • Atorvastatin(Lipitor) 10 mg tablet PO daily
  • Escitalopram(Lexapro) 10mg tablet PO daily

Surgical History:

  • (Right breast negative BRCA-1990 October 30th – s/p mastectomy)

Immunization History:

  • Pfizer SARS-COV2-Vaccine: 10/01/21, 03/31/21, 03/02/21
  • Bivalent Pfizer SARS-COV2-Vaccine: 09/15/22
  • Influenza: 10/09/2023
  • TDAP: 05/17/2022

Allergies: 

  • No known drug/food/environmental allergies

Family History:

  • Mother: Deceased age 93.No known medical hx.
  • Father: Deceased age 89 . Hx HTN,DM II.
  • 2 children: Alive and well, live in New Jersey, not in contact.

Social History:

  • Smoking: Never
  • Alcohol: Never
  • Denies past or current illicit drug use
  • Marital History: Divorced(1994), currently single
  • Language: English
  • Education: High school graduate
  • Occupational History: Retired, finance assistant at Cornell University 
  • Travel: No recent travel
  • Home situation: Patient lives alone in an apartment building in Manhattan, NY. 11th floor studio with elevator in building.
  • Sleep: Patient states she sleeps well with about 7-8 hours daily. States burning sensations worsens when she lies down in bed.
  • Exercise: Patient states she can walk 10 blocks without feeling significantly fatigued.States that she walks daily. 
  • Diet: Admits to a balanced diet with proteins, grains, vegetables.
  • Caffeine: Denies caffeine intake 
  • Sexual history: Not currently sexually active. No known history of STIs.

ROS:

  • General: Denies fatigue, fever, chills, night sweats, weight loss, changes in appetite.
  • Skin, hair, nails: Denies discolorations, moles, rashes, changes in hair distribution or texture, pruritus.
  • HEENT: Denies head trauma, vertigo, visual disturbances, ear pain, hearing loss, tinnitus, epistaxis, discharge, congestion, sore throat, bleeding gums. Patient states last dental visit was about 2 years ago. Last ophthalmology visit 1 year ago.
  • Neck: Denies localized swelling/lumps, stiffness/decreased ROM
  • Breast: Last mammogram(09/25/2023)no malignant findings, Denies pain, swelling, discharge.
  • Pulmonary: Denies cough, dyspnea, wheezing, cyanosis, hemoptysis.
  • Cardiovascular: Admits to pyrexia. Denies chest pain, edema/swelling of ankles or feet, palpitations.
  • Gastrointestinal: Admits to reflux. Denies any nausea, vomiting, diarrhea, constipation, dysphagia.
  • Genitourinary: Denies urgency, frequency, incontinence, hesitancy, dribbling.
  • Musculoskeletal: Denies muscle pain, joint pain, arthritis, or swelling.
  • Nervous system: Denies seizures, headache, loss of strength, change in cognition/mental status/memory.
  • Peripheral vascular: Denies intermittent claudication, varicose veins, coldness of extremities, color changes, peripheral edema.
  • Hematologic: Denies anemia, easy bruising or bleeding, lymph node enlargement, history of DVT/PE.
  • Endocrine: Denies polydipsia, polyphagia, heat or cold intolerance, excessive sweating.
  • Psychiatric: Admits to being anxious,causing her to skip meals.

Physical Exam:

Vitals: 

  • Weight: 147  lb Height: 64 inches   BMI: 25.2 kg/m2
  • BP: 132/72, left arm sitting
  • RR: 17, unlabored
  • HR: 84, regular
  • Temp: 97.3 F oral
  • SpO2: 97% room air

General: 82 year-old obese female who appears stated age. Well-groomed and good posture. A/O x 3 and appears in no acute distress.

Skin: Warm, dry & intact. No rashes, cyanosis, moles, or lesions noted.

Head: Normocephalic & atraumatic

Eyes: Symmetrical OU. Sclera white, cornea and lens clear and conjunctiva pink. PERRL. EOM intact with no nystagmus.

Ears: Ears symmetric and appropriate in size. No lesions or masses on the external ear. TM clearly visualized, pearly gray & in good position AU. Auditory acuity intact to whispered voice AU.

Nose: Symmetrical. No rhinorrhea noted. Nares patent B/L.

Mouth/Throat: Mucus membranes moist. Pharynx non-erythematous. No exudates present.

Neck: Trachea midline. Neck supple and nontender. No lymphadenopathy present. Carotid pulses 2+. Right sided carotid artery bruit auscultated. FROM without pain.

Thyroid: Non-tender to palpation, no thyromegaly noted, no palpable nodules or masses.

Heart: Regular rate and rhythm. S1 & S2 distinct with no murmurs or gallops.

Chest: Symmetrical, no deformities. Non-tender to palpation. Chest expansion symmetrical with no accessory muscle use.

Lungs: Clear to auscultation B/L. No adventitious sounds noted.

Abdominal: Abdomen symmetric and non-distended, with no striae or scars. Normoactive bowel sounds in all 4 quadrants. Non-tender to palpation and tympanic throughout with no guarding or rebound. No abdominal hernias noted. No CVA tenderness appreciated. Negative Murphy’s sign.

Neurologic: Alert and oriented to person, place and time. Cranial nerves intact Symmetric light and dull touch in bilateral upper and lower extremities.Mini-Cog: 5/5 

Musculoskeletal: No soft tissue swelling, erythema, ecchymosis or deformities.

Peripheral vascular: Extremities are symmetrical and normal in size, color and temperature. No edema or stasis changes noted. Pulses 2+ bilaterally in upper and lower extremities. No calf tenderness.

Foot exam: Skin is warm and intact. No edema, erythema, lesions or ulcers notes. Nails well-trimmed and appropriate in length. 2+ dorsalis pedis and posterior tibial pulses bilaterally.

Ddx 

Gerd

PUD 

Gastritis

Cholelthiasis  

Assessment/Plan:

82 y/o female with Pmhx of HTN,hyperlipidemia, Gerd, anxiety disorder comes in today with GERD like symptoms not being controlled with 20mg Famotidine twice daily. ROS and HPI elicits that the patient is continuing to have heartburn and acid reflux symptoms despite being started on Famotidine. Patient also states worsening of her anxiety symptoms causing her to skip meals every other day. 

#GERD

  • Change H2 to PPI,Pantoprazole(Protinix) 40 Mg tablet
  • Referral to GI(Long standing gerd symptoms- for upper endoscopy.) 

#Anxiety/Depression 

  • Refill Escitalopram(lexapro) 10 mg tablet
  • Referral to psychological counseling
  • Psychological condition will be reassessed in 4 weeks  

#HTN

  • HTN improving with treatment(continue current treatment regimen) 
  • Atenolol(Tenormin) 25 mg tablet
  • Losartan(Cozaar) 50 mg tablet

#Hyperlipidemia

  • Lipid abnormalities are improving with treatment 
  • Nutritional counseling was provided)
  • Refill Atorvastatin(Lipitor) 10 mg tablet