Daniel DeMarco                                              H&P #3                                    Internal Medicine

Chief Complaint: Difficulty breathing

History of Present Illness:

LL is a 63yo female HD5 with PMH asthma, immune deficiency on IVIG, chronic sinusitis, breast cancer s/p left sided mastectomy (2007) admitted with status asthmaticus. This started a week and a half ago when the patient started having increased difficulty breathing and wheezing. Her difficulty breathing was not exertional and did not involve chest pain. She states that it felt “just like one of my asthma exacerbations.” She tried using her home medications with no relief. She has been hospitalized several times in the past for status asthmaticus but has never required intubation. At this time, she endorses cough, SOB, wheezing. Denies fever, chills, nausea, vomiting.

Past Medical History: Asthma, Immune Deficiency on IVIG, Chronic Sinusitis, Breast Cancer

Past Surgical History: Left Sided Mastectomy (2007)

Allergies: Penicillin – Rash; Pollen and Seasonal Allergies; Denies Food Allergies

Medications: Albuterol inhaled 2.5mg NEB tid-qid prn, Arformoterol inhaled 15mcg NEB q12h, Umeclidinium inhaled 62.5mcg 1 puff qd, Montelukast 10mg PO qd, Fexofenadine 1 tab PO q12h prn, Guaifenisin 1-2 tab PO q12h prn, Hydrocodone/homatropine 1 tab PO q4-6h prn, Melatonin 10mg PO qhs

Social History: Lives with husband. Non-smoker. No EtOH use. No illicit drug use.

Family History: Father, Deceased, 82yo, DM2, CVA; Mother, Deceased, 91yo, Breast Cancer;

Review of Systems :

General : Admits weakness, fatigue. Denies fever, chills, night sweats, loss of appetite, weight

loss

Skin, Hair, Nails : Denies change in texture, excessive dryness or sweating, discolorations,

pigmentations, moles, rashes, pruritus, change in hair distribution

Head : Admits headache. Denies trauma, unconsciousness, coma, fracture, vertigo

Eyes : Denies corrective lenses, visual disturbances, fatigue, photophobia, pruritus, lacrimation,

Last Eye Exam: 8/2016, Dr. Jo

Ears : Denies deafness, pain, discharge, tinnitus, hearing aids

Nose/Sinuses : Admits obstruction. Denies discharge, epistaxis, rhinorrhea

Mouth/Throat : Denies bleeding gums, sore tongue, sore throat, mouth ulcers, voice changes,

dentures, Last Dental Exam: 01/2018, Dr. Aiello

Neck : Denies lumps, swelling, stiffness, decreased range of motion

Breast : Denies lumps, nipple discharge, pain

Respiratory : Admits dyspnea, shortness of breath, wheezing, cough productive of greenish sputum. Denies hemoptysis, cyanosis, orthopnea, paroxysmal nocturnal dyspnea

Cardiovascular : Denies palpitations, irregular heartbeat, edema, syncope, chest pain, known heart murmur

Gastrointestinal : Denies change in appetite, abdominal pain, intolerance to specific foods, nausea, vomiting, dysphagia, pyrosis, flatulence, eructations, diarrhea, constipation, hemorrhoids, change in stool caliber, blood in stool

Genitourinary : Denies change in frequency, urgency, hesitancy, dribbling, nocturia, polyuria, oliguria, dysuria, change in urine color, incontinence, flank pain

Musculoskeletal : Denies muscle pain, joint pain, deformity, swelling, redness, arthritis

Peripheral Vascular : Denies intermittent claudication, coldness or trophic changes, varicose veins, peripheral edema, color change

Hematologic : Denies anemia, easy bruising/bleeding, lymph node enlargement, history of DVT/PE

Endocrine : Denies polyuria, polydipsia, polyphagia, heat or cold intolerance, goiter, hirsutism

Neurologic : Denies seizures, loss of consciousness, sensory disturbances, paresthesia, dysesthesia, hyperesthesia, ataxia, loss of strength, change in mental status, memory loss, asymmetric weakness

Psychiatric : Denies feelings of helplessness, feelings of hopelessness, lack of interest in usual activities, suicidal ideation, anxiety

 

Physical Exam :

Vital Signs :

T 36.3C

BP 122/56

P 108 bpm

RR 11 breaths/min

SpO2 100% BiPAP

 

General Survey : Appears her stated age. AOx3. No apparent distress. Speaking in full sentences but frequent coughing.

Skin : Warm and moist, good turgor. Nonicteric. No lesions, tattoos.

Head : Normocephalic, atraumatic. Nontender to palpation throughout.

Chest : Left chest with well-healed scar s/p mastectomy. No paradoxical respirations or accessory muscle use. Unlabored respirations. LAT to AP diameter 2:1. Nontender to palpation.

Lungs : Frequent coughing. Wheezing bilaterally. No rhonchi, rales, dullness.

Cardiovascular : Regular rate and rhythm. S1 and S2. No murmurs, S3, S4, splitting of heart sounds, friction rubs.

Abdomen : Soft, non-distended. Non-tender to palpation throughout. No scars, striae, caput medusa, or abdominal pulsations. BS present in all four quadrants. No bruits over aortic/renal/iliac/femoral arteries. No masses, guarding, rebound tenderness, CVAT.

Extremities/Peripheral Vascular : Extremities symmetric in color, size, and temperature. Pulses are 2+ bilaterally. No clubbing, cyanosis, or edema. No stasis changes or ulcerations.

 

Labs :

3/18/2019

8.4

9.17> 30.6 <291

141 |107 | 13 < 63

4.1  | 25  | 0.8

9.4   | 22.5

^

0.9

Sputum Culture: No growth

Respiratory Viral Panel: Negative

 

A/P

LL is a 63yo female HD5 with PMH asthma, immune deficiency on IVIG, chronic sinusitis, breast cancer s/p left sided mastectomy (2007) admitted with status asthmaticus.

Respiratory

#Status Asthmaticus – Improving

#Asthma

#Chronic Sinusitis

– Cont. Doxycycline 100mg PO bid x 7d (per Pulmonary)

– Cont. Methylprednisolone sodium succinate 70mg IV q6h

– Cont. Levalbuterol inhaled 1.25mg NEB tid prn

– Epinephrine inhaled 2.25% NEB q6h prn

– Cont. Arformoterol inhaled 15mcg NEB q12h, Umeclidinium inhaled 62.5mcg 1 puff qd, Montelukast 10mg PO qd, Fexofenadine 1 tab PO q12h prn

– Cont. Guaifenesin 1-2 tab PO q12h prn, Hydrocodone/homatropine 1 tab PO q4-6h prn

– Cont. BiPAP – IPAP 10 cmH20, EPAP 4 cmH20, FiO2 titrated to keep SpO2 >92%

– Chest PT bid

– Repeat CBC, BMP, Mg2+ in AM

– Importance of medication compliance reviewed. Advised patient to attempt to limit exposure to asthma triggers. Common asthma triggers reviewed.

 

Hematologic

#Primary Immunodeficiency

– Diphenhydramine 50mg IV one time and Acetaminophen 325mg PO one time 30min. prior to midline placement

– IVIG after midline placement

 

Neurologic

#Difficulty Sleeping

– Melatonin 10mg PO qhs

 

Oncologic

#Breast Cancer – s/p Left Sided Mastectomy (2007)

– F/u with PMD (Dr. Joelle Marcy)

– F/u with Oncologist (Dr. Borchardt)

– Discussed breast self-awareness with the patient and advised her to continue regular follow ups and screening per her PMD and oncologist

 

DVT Prophylaxis: IPC and Heparin SubQ

Nutrition: Full, Unrestricted Diet

Dispo: Anticipate discharge in 2-3d pending control of status asthmaticus

 

Case discussed with Dr. Mathew MD who agrees with A/P.

 

/s/ Daniel DeMarco, PA-S

Physician Assistant Student