Full Name: I.M.
Date & Time: 10:45AM on 09/14/2021
Location: New York, NY
Marital Status: Widowed
Source of Information: Self
Source of Referral: Urgent Care
Chief Complaint: “I noticed my pulse getting high and blood pressure was running lower than normal” x1 week
History of Present Illness:
87 y/o covid negative female with PMHx of MI x1, AFib x1, HTN, NIDDM was sent to the ER by Urgent Care 3 days prior for atrial fibrillation Dx on ECG. She was treated with Metoprolol 25 mg PO and subsequently admitted to internal medicine for a UTI, currently being treated with Ceftriaxone 1g IV 1x daily. Metoprolol 5mg IV bolus given this morning for recurrent AFib. She routinely checks her BP with an at-home monitor x1 daily in the A.M. and noticed her HR was elevated (~135 bpm, reported baseline ~60-70bpm) and systolic BP 20 mmHg lower (SBP ~115 mmHg, baseline SBP ~135mmHg) x1 week which prompted her to visit urgent care. She denies recent changes in medications and has continued them as prescribed. No attributable factors that have worsened or improved vitals. She denies any pain/discomfort (rated 0/10 severity). She denies having any associated Sx or recent complaints. She notes having “gastritis” 3 weeks prior causing generalized abdominal pain, flatulence, and diarrhea after meals, but reports symptoms have resolved since starting the BRAT diet 2 weeks ago. She denies chest pain, palpitations, feeling an irregular heartbeat, edema/swelling of ankles/feet, syncope, fever, AMS, changes in urinary frequency, nocturia, urgency, oliguria, polyuria, dysuria, abnormal color of urine, incontinence, or flank pain.
Past Medical History:
- Cardiovascular Disease – x16 yrs
- Hypertension – x16 yrs
- Type 2 Diabetes Mellitus – unknown duration
- Colon Cancer – Dx 1991, Remission since 1991
- Wet Macular Degeneration bilateral – >30 yrs
- Hospitalization for Myocardial Infarction (2005), Atrial Fibrillation (2013), Endocarditis (2014)
- Up-to-date on immunizations
- Vaccinated against SARS-CoV-2
Past Surgical History:
- LAD Stent (MI) – 2005
- Partial Colectomy (Colon Cancer) – 1991
- 18 Inches resected
- Subsequent intestinal adhesions requiring surgical removal – 1991
- (FMHx Colon Ca)
- Laser surgery on left eye (Macular Degeneration) – 1991
- TAH-BSO (Uterine Fibroids) – 1983
- No prior transfusions
- No complications of surgical procedures other than adhesions from colectomy
- Ceftriaxone 1g IV 1x daily – Urinary Tract Infection
- Metoprolol 25 mg PO or 2.5 mg IV PRN – Atrial Fibrillation
- Atorvastatin 10mg 1x daily – CVD
- Clopidogrel 75mg 1x daily – CVD
- Valsartan 160mg 1x daily – HTN
- Amlodipine 10mg 1x daily – HTN
- Metformin 1000mg 2x daily – NIDDM
- Olopatadine ophthalmic solution 2.5ml of 0.2% 1x daily – Allergic Conjunctivitis
- Eylea (dosage unknown) q4weeks – Wet Macular Degeneration
- B complex vitamin OTC 1x daily
- Folic Acid OTC 1x daily
- Omega-3 Fatty Acid OTC 1x daily
- Vitamin D 2000 IU OTC 1x daily
- Penicillin – Itchy Rash after receiving IV Abx for Endocarditis 2014
- No known food or environmental allergies
- Mother – Colon Cancer [cause of death] (Deceased, 44 y/o)
- Father – Dementia, HTN, MI [cause of death] (Deceased, 94 y/o)
- Maternal Grandmother – unknown
- Maternal Grandfather – unknown
- Paternal Grandmother – Dementia
- Paternal Grandfather – unknown
- Paternal Aunt – Dementia
- Paternal Uncle – Dementia
- Siblings – 1 brother, healthy & living (age unknown)
- Habits – alcohol (denies ever using), never smoked tobacco, never used marijuana or other illicit drugs, caffeine use (rarely)
- Travel – no recent travel
- Occupation – Retired elementary school teacher
- Marital History – Widowed, living alone. No pets
- Cared for by brother. Stays socially active through Pilates classes.
- Diet – Following the BRAT Diet x3 weeks for reported gastritis. Otherwise, has no dietary restrictions. Reports eating 3 meals per day consisting of protein, fruits, & vegetables.
- Sleeps 9 hrs/night (10:30PM-7:30AM). Feels rested and sleeps through the night.
- Exercise – Pilates class 2-3x per week
- Safety measures – wearing seatbelt. Does not engage in sports that require helmet use
- Sexual History – 1 prior monogamous relationship with a male. Not currently sexually active. Denies anorgasmia, no history of STDs, not using contraception.
Review of Systems:
- Denies recent weight loss/gain, loss of appetite, generalized weakness/fatigue, fever/chills/night sweats
- Skin, hair, nails
- Denies excessive sweating, pigmentations, moles, change in hair distribution, pruritis, xerosis
- Denies headache, vertigo, head trauma
- Admits to seasonal pruritis
- Denies visual disturbances, abnormal lacrimation, photophobia
- Last eye exam 1 yr prior (No change in vision). Visual acuity unknown. Wears prescription glasses for macular degeneration & receiving anti-VEGF therapy q4wks
- Denies deafness, pain, discharge, tinnitus, hearing aids, or feeling of fullness
- Denies epistaxis, congestion, or discharge
- Mouth and Throat
- Denies bleeding gums, sore tongue/throat, mouth ulcers, voice changes, or dentures. Last dental exam unknown
- Denies swelling/lumps, stiffness, or decreased ROM
- Denies lumps, nipple discharge, or pain. Last mammogram unknown
- Pulmonary System
- Denies SOB, DOE, cough, wheezing, hemoptysis, cyanosis, orthopnea, or PND
- Cardiovascular System
- Admits to Hx of HTN
- Denies known murmur, chest pain, palpitations, irregular heartbeat, edema/swelling of ankles/feet, or syncope
- Gastrointestinal System
- Denies changes in appetite, intolerance to specific foods, N/V/D, dysphagia, pyrosis, flatulence, abdominal pain, jaundice, changes in bowel habits, hemorrhoids, constipation, rectal bleeding/blood in stool, or constipation. Last colonoscopy unknown
- Genitourinary System
- Denies changes in frequency, nocturia, urgency, oliguria, polyuria, dysuria, abnormal color of urine, incontinence, or flank pain
- Sexual History – refer to Social Hx
- Menstrual and Obstetrical
- Last regular period 48 y/o (s/p TAH-BSO)
- Menarche age unknown
- Denies postcoital bleeding, abnormal vaginal discharge, or dyspareunia
- Nervous System
- Denies seizures, headache, loss of consciousness, sensory disturbances, ataxia, loss of strength, change in cognition/mental status/memory, or weakness
- Musculoskeletal System
- Denies muscle/joint pain, deformity, swelling, redness, or Hx of arthritis
- Peripheral Vascular System
- Denies intermittent claudication, coldness/trophic changes, varicose veins, peripheral edema, or color change
- Hematologic System
- Denies anemia, easy bruising/bleeding, lymph node enlargement, prior blood transfusions, or history of DVT/PE
- Endocrine System
- Denies polyuria/polydipsia/polyphagia, heat/cold intolerance, goiter, excessive sweating, or hirsutism
- Denies depression/sadness, anxiety, or obsessive/compulsive disorder. Never seen a mental health professional. Never taken psychiatric medications
BP: 112/72 mmHg – sitting & supine, L arm
RR: 16 breaths/min, unlabored
Pulse: 86 bpm, regular
T: 37.1 C (oral)
O2 SAT: 95% room air
Height: 63 inches Weight: 116 lbs BMI: 20.5
General Appearance: alert, oriented, not distressed, appropriate development, well nourished, appropriate posture, appears stated age, well dressed
Head: normocephalic, atraumatic, non-tender to palpation throughout
Eyes: Symmetrical OU. No strabismus/exophthalmos/ptosis. Sclera white, cornea clear, conjunctiva pink. No erythema of lacrimal sack. Corrected visual acuity 20/20 OU. Visual fields full OU. PERRLA. EOM intact with no nystagmus. Red reflex intact OU. Retinal vessels unremarkable (no AV nicking, hemorrhages, exudates, or neovascularization). Optic disc unremarkable (cup-to-disc ratio < 0.5 OU with appropriate color & contour), no papilledema. Exudates around the Macula & fovea with discoloration, macular degeneration bilaterally
Ear: Appropriate in size. Ear and tragus nontender AU. No lesions/masses/trauma visualized on external ear. No discharge/foreign bodies in external auditory canals AU. TM pearly white/intact with cone of light in appropriate position AU. Non-obstructing cerumen noted in the ears bilaterally. Auditory acuity intact to whisper voice AU. Weber midline / Rinne AC>BC AU.
Nose: Symmetrical, no masses/lesions/deformities/trauma/discharge. No tenderness/bogginess/step off to palpation. Nares patent bilaterally. Nasal mucosa pink & moist. Septum midline. Inferior nasal turbinate hypertrophy and clear mucus visualized on anterior rhinoscopy. No ulcerations/foreign bodies visualized.
Sinuses: No tenderness to palpation over bilateral maxillary/frontal sinuses.
Mouth & Throat:
Lips: Pink & moist. No cyanosis, lesions, or ulcerations
Oral Mucosa: Pink, well hydrated. No masses/lesions noted. No leukoplakia.
Palate: Pink, well hydrated. No visible lesions/masses/scars.
Teeth: No dental caries, missing, or loose teeth. All teeth have appropriate shape.
Gingivae: No hypertrophy or recession. Unremarkable
Tongue: pink, well papillated. Frenulum intact. No masses/lesions/deviation.
Oropharynx: Well hydrated, no exudate/masses/lesions/foreign bodies noted. Grade 1 tonsils. Uvula pink, midline with no lesions or edema.
Neck: Trachea midline. No masses/lesions/pulsations noted. Neck supple, non-tender to palpation. Free range of motion. No stridor noted. No cervical adenopathy. No carotid pulses/thrills/bruits heard on auscultation. Thyroid is non-palpable, unremarkable. No goiter
Lymph nodes: Non-palpable, unremarkable preauricular, postauricular, submandibular, posterior cervical chain, anterior cervical chain, supraclavicular, and infraclavicular lymph nodes
Cardiovascular: JVP is 2.5cm above sternal angle with head of bed at 30 degrees. PMI located at the 5th ICS in midclavicular line. Carotid pulses are 2+ bilaterally without bruits. RRR. S1/S2 distinct with no murmurs or S3/S4 heard. No splitting of S2 or friction rubs appreciated.
Chest: Symmetrical with no deformities or trauma. No tenderness on palpation. Respirations unlabored, no paradoxical respirations or use of accessory muscles. Lat/AP diameter 2:1.
Lungs: Clear to auscultation and percussion bilaterally. Chest expansion/diaphragmatic excursion symmetrical. No adventitious sounds. Tactile fremitus throughout.
Abdomen: Abdomen symmetric and flat. No scars, striae, or pulsations noted. Bowel sounds are normoactive in all 4 quadrants. No aortic/renal/iliac/femoral bruits heard. Non-tender to palpation and tympanic throughout. No guarding or rebound tenderness. No hepatosplenomegaly to palpation. No CVA tenderness appreciated.
Skin: Warm and moist with patches of xerosis. Good turgor. Non-icteric. No tattoos noted. No moles.
Hair: Average quantity and distribution. No seborrhea/lice/dandruff noted
Nails: No clubbing, capillary refill < 2 seconds in upper & lower extremities, appropriate shape & color.
Musculoskeletal: Appropriate alignment of spine. Full ROM. No joint erythema or tenderness. Appropriate muscular development. Normal gait
Neurological: CN 2-7 intact. Strength & sensation symmetric & intact. Reflexes 2+ throughout. Cerebellar testing WNL.
Psychiatric: Oriented to person, place, & time. Good judgement/reason w/o abnormal affect, hallucinations, or abnormal behavior.
- Atrial Fibrillation – Dx on ECG
- Urinary Tract Infection – Dx by UA + culture
- Macular Degeneration bilaterally – stable, being followed by ophthalmologist
- Atrial Fibrillation:
- Metoprolol 2.5-5g IV bolus PRN for AFib rhythm
- Order repeat cardiac enzymes 1x daily
- Continue monitoring on Telemetry
- Consult Cardiology on when to discharge
- Have patient follow up with their cardiologist
- Urinary Tract Infection:
- Continue Ceftriaxone 1g IV daily with IV fluids
- Consult infectious disease on duration during hospital stay and discharge antimicrobial therapy PO
- Repeat UA with culture before discharge
- Tylenol 325mg 1 or 2 tabs PO q6hrs PRN for mild pain or temp >100.4
- Do not exceed 3 grams of acetaminophen in 24 hrs
- Monitor fasting glucose q.a.m.
- Order TSH/Free T4 to assess for Hyperthyroidism
- Continue all routine medications as prescribed
- Order baseline labs
- CBC, CMP 1x daily
- Monitor vitals q6h
- Atrial Fibrillation
- Myocardial infarction
- Coronary Stent Failure
- Urinary Tract Infection
- Cystitis secondary to UTI
- Hyperthyroidism ***tachycardia + abdominal Sx