LTC HPI 2

Chief Complaint: “Follow up for my high blood pressure”

 History of Present Illness:

84 y/o female with a past medical history of HTN, hyperlipidemia, GERD, prediabetes and osteopenia comes in today for blood pressure follow up. Patient was last seen on 02/21/2024 where BP in office was 157/77. Patient’s medication was increased from  Losartan 50mg to 100mg PO (once daily in the morning) and metoprolol 50 mg nightly PO (once daily) with  follow up in 4-6 weeks and reassessment. Patient was also prescribed a blood pressure monitor and told to log her readings daily. Patient logs show blood pressure ranging from 151/85- 143/82.

Patient’s blood pressure reading this morning after breakfast was 146/84. Patient denies any caffeine intake. Patient states she is compliant with her medications and takes both pills at the directed time. Patient states she has also incorporated a sodium restricted diet to help lower her blood pressure. Patient has no acute complaints currently and states she is feeling “happy to be here.” Patient denies any chest pain, shortness of breath, dizziness, lightheadedness, confusion, fatigue, fainting, blurry vision. 

Geriatric Assessment

  • ADLs: Independent in all
  • IADLs: Independent in all
  • Home Health Aide: None
  • Visual impairment: Yes –Glasses
  • Hearing impairment: None
  • Falls in the past year: None
  • Assistive devices used: Yes- Walking cane 
  • Gait impairment: None
  • Urinary incontinence: None
  • Fecal incontinence: None
  • Osteoporosis: No(Osteopenia, Dexa input  -2.1)
  • Cognitive Impairment: None – Mini-cog: 5/5
  • Depression: None 
  • Home safety issues: None
  • Health Care Proxy: Yes(Son) 
  • Advance Directives: Full code

Past Medical History

Medical History:

  • HTN
  • Hyperlipidemia
  • GERD
  • Prediabetes  
  • Osteopenia

Medications:

  • Losartan(Cozaar) 100mg tablet PO daily
  • Metoprolol succinate  50 mg tablet PO daily
  • Ammonium lactate(LAC-HYDRIN) 12 % solution
  • Cholecalciferol(VIT D3) 1000 unit tablet  
  • Omeprazole (PRILOSEC) 20 mg capsule PO daily

Surgical History:

  • 01/01/1972- Hysterectomy

Immunization History:

  • Pfizer SARS:COV2-Vaccine: 03/16/21, 11/04/21, 08/09/22
  • Bivalent Pfizer SARS-COV2-Vaccine: 05/17/23
  • Influenza: 10/20/2023
  • TDAP: 08/05/2016
  • Pneumovax 23: 05/07/2021
  • SHINGRIX: 06/10/2022,10/05/2021

Allergies: 

  • No known drug/food/environmental allergies

Family History:

  • Mother: Deceased age 90.Hx of HTN
  • Father: Deceased age 85 . No Hx documented 
  • 1 Son: Alive and well, lives in florida 
  • Sister: Helps her on rare occasions 

Social History:

  • Smoking: Never
  • Alcohol: Never
  • Denies past or current illicit drug use
  • Marital History: Widowed(2020)
  • Language: Spanish
  • Education: High school level education in D.R
  • Occupational History: Housewife
  • Travel: No recent travel
  • Home situation: Patient lives alone in rental apartment Manhattan, NY. 
  • Sleep: Patient states no disturbances in sleep 
  • Exercise: Patient denies doing regular physical activity but states she is able to independently do all her daily activities.
  • 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 over 10 years ago.
  • Neck: Denies localized swelling/lumps, stiffness/decreased ROM
  • Breast: Denies pain, swelling, discharge.
  • Pulmonary: Denies cough, dyspnea, wheezing, cyanosis, hemoptysis.
  • Cardiovascular: Denies chest pain, edema/swelling of ankles or feet, palpitations.
  • Gastrointestinal: 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: Denies depression/sadness, anxiety,  or ever seeing a mental health professional.

Physical Exam:

Vitals: 

  • Weight: 117  lb Height: 4 feet 9 inches  BMI: 24.9 kg/m2
  • BP: 148/90 , left arm sitting 152/88, right arm sitting
  • RR: 16, unlabored
  • HR: 70, regular
  • Temp: 97.4 F oral
  • SpO2: 97% room air

General: 84 year-old 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: Left internal pterygium. No scleral icterus,discharge .extraocular movements intact. Pupils are equal, round and reactive to light.

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 

Uncontrolled HTN 

Assessment/Plan:

84 y/o female with a past medical history of  HTN, hyperlipidemia, GERD, prediabetes,osteopenia presents today with uncontrolled blood pressure. Patient blood pressure is not being controlled on losartan 100mg(once daily)and metoprolol 50mg(once daily), and will need third medication to help bring down her current BP. Patient today is also due to the RSV vaccine and will receive a dose. 

#HTN

  • Continue Losartan 100mg AM and Metoprolol 50 mg po at night
  • Add 2.5 mg Amlodipine in AM and follow up in 4 weeks nurse visit- if BP remains elevated to increase to 5 mg amlodipine AM

#Hyperlipidemia

  • Lipid abnormalities are improving with lifestyle modifications
  • Nutritional counseling was provided, lipids will be reassessed next visit

#Osteopenia

  • Continue with vit D and calcium supplementation and weight bearing exercise 

#Vitamin D deficiency 

  • On oral supplementation(continue Cholecalciferol  1000 unit tablet)

#GERD

  • On diet and PPI- symptoms controlled

#Pre-Diabetes

  • Diet and weight control

#Dry skin

  • Ammonium Lactate 12% lotion on area

#Healthcare Maintenance

  • RSV vaccine today