Chief Complaint: “Nothing is bothering me.” Re-Admission to Margaret Tietz Nursing and Rehabilitation Center.

HPI:

JS is a 76yo Guyanese Female with PMH COPD on 2L Home O2, HTN, HLD, DM2, HFpEF, CKD IV who was transferred from Margaret Tietz Nursing and Rehabilitation Center to Queens Hospital Center on 10/11/2019 following a syncopal episode. The patient stated that she was sitting on the toilet on the morning of 10/11/2019 when she “felt like I was going to pass out.” She denied any chest pain, palpitations, shortness of breath, or headache preceding the syncopal episode. Patient admitted loss of consciousness during the syncopal episode. The episode was witnessed by the patient’s CNA, who immediately consulted the nurse and the physician. The patient did not fall from the toilet, and she did not strike her head. The patient was not easily arousable, and the decision was made to call the ambulance and have her transferred to QHC for further evaluation. The patient reported that she has never experienced this before, but denied any complaints at the time of transfer to QHC. Patient received Acetaminophen, 1L NS bolus, and ED work up found that the patient had Guaiac positive stool. Patient was admitted to the internal medicine floor and was found to have initially elevated troponin to 0.018 and mild T-wave inversions which later trended down, and EKG changes resolved. Cardiology was consulted and concluded that the findings were likely 2/2 to CKD. Patient had negative head CT and echocardiogram did not reveal wall motion abnormalities. Patient had repeat CT chest that revealed recurrent mucus plug in left lower lobe. Pulmonology was consulted and recommended continued bronchodilators, suctioning, and chest PT. Labs revealed Vitamin D of 15.8 and patient was discharged on Vitamin D supplementation with Cholecalciferol 1000u tab, take 1 tab PO qd. Patient was transferred and re-Admitted to Margaret Tietz Nursing and Rehabilitation Center on 10/16/2019.

Currently, patient denies any acute complaints, stating “nothing is bothering me.” Denies weakness, fever, chills, headache, nausea, vomiting, diarrhea, constipation, palpitations, chest pain, dyspnea, shortness of breath, cough, abdominal pain, calf swelling. She reports that her appetite is normal and that she is having daily formed bowel movements.

PMH: COPD (2L Home O2), HTN, HLD, DM2, HfpEF, CKD IV

PSH: None

Medications:

Albuterol 108 (90 base) mcg/act inhaler, inhale 2 puffs bid

Amlodipine 10mg tab, 1 tab PO qd

ASA 81mg chewable tab, 1 tab PO qd

Atorvastatin 20mg tab, 1 tab PO qhs

Budesonide-formoterol 80-4.5 mcg/act inhaler, inhale 2 puffs bid

Carvedilol 25mg tab, take 1 tab PO bid

Cholecalciferol 1000u tab, take 1 tab PO qd

Hydralazine 25mg tab, take 3 tab PO tid

Ipratropium-albuterol 0.5-2.5mg/3mL nebulizer, take 3mL by nebulization q6h

Isosorbide dinitrate 5mg tab, take 1 tab PO q8h

Metformin ER 500mg tab, take 1 tab PO bid

Sodium chloride 3% nebulizer solution, take 4mL nebulizer bid

Allergies: Shellfish-derived products

Social History:

The patient is widowed and lives in a house alone. She ambulates using a walker and is able to transfer on her own. She does not have an aid. The patient is a retired nurse. She had exposure to wood cooking for years before immigrating from Guyana to the US in 1960. She had second hand smoke exposure from her husband.

Denies current or past smoking history. Denies EtOH use. Denies illicit drug use.

Family History:

Mother, Deceased, HTN, HLD

Father, Deceased, HTN, HLD, DM2

Review of Systems:

General : Denies fever, chills, weakness, night sweats, fatigue, 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 : Denies headache, trauma, unconsciousness, coma, fracture, vertigo

Eyes : Denies corrective lenses, visual disturbances, fatigue, photophobia, pruritus, lacrimation, Last Eye Exam: 10/2018, Dr. Juju

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

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

Mouth/Throat : Denies bleeding gums, sore tongue, sore throat, mouth ulcers, voice changes, dentures, Last Dental Exam: 04/2018, Dr. Guan

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

Breast : Denies lumps, nipple discharge, pain, Last Mammogram: 06/2017, Dr. Cortes

Respiratory : Denies wheezing, hemoptysis, cyanosis, dyspnea, shortness of breath, cough, paroxysmal nocturnal dyspnea

Cardiovascular : Denies palpitations, chest pain, irregular heartbeat, edema, syncope, 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 deformity, swelling, redness, weakness, muscle pain, joint pain

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 36.8C

BP 124/70

P 76bpm

RR 12 breaths/min

SpO2 100% 2L NC

Ht: 62in. Wt: 110 lbs. BMI: 20.0 kg/m^2

General Survey : 76yo female, A/O x3. Resting comfortably in bed. NAD.

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

Nails : No clubbing, lesions. Capillary refill <2s throughout.

Hair : Average quantity and distribution.

Head : Normocephalic, atraumatic. Nontender to palpation throughout.

Eyes : No conjunctival injection, pallor, or scleral icterus. EOMS full.

Ears : Symmetrical. No lesions/masses on external ears. No discharge.

Nose : Symmetrical. No masses, lesions, deformities, or discharge. Nares patent b/l. Nasal mucosa pink and well-hydrated.

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

Mouth : Lips pink, moist, no lesions/cyanosis. Mucosa pink, well-hydrated. No masses/lesions/leukoplakia. Palate pink and well-hydrated, intact with no lesions. Good dentition. Gingivae pink and moist without hyperplasia. Tongue pink and well-papillated. Oropharynx well-hydrated, uvula pink, midline, no edema.

Neck : Trachea midline. No masses, lesions, scars. Supple, nontender to palpation. Full range of motion. No palpable lymphadenopathy.

Thyroid : Non-tender to palpation. No thyromegaly, goiter.

Chest : Symmetrical. No deformities. No paradoxical respirations or accessory muscle use. Respirations unlabored. LAT to AP diameter 2:1. Nontender to palpation.

Lungs : Resonant to percussion throughout. Clear to auscultation bilaterally. No wheezing, rhonchi, or rales.

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

Abdomen : Soft, non-distended. Non-tender to palpation throughout. No 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.

Mental Status : Alert and oriented to person/place/time. Attention intact. Memory intact. Receptive an expressive abilities intact. Thought coherent. No dysarthria, dysphonia or aphasia noted.

Cranial Nerves :

– CNI: Nares patent bilaterally. No anosmia.

– CN II: Visual acuity 20/40 OS, 20/30 OD, 20/30 OU. Visual fields full and red light reflex OU.

– CN III, IV, VI: PERRL. EOMs intact without nystagmus.

– CN V: Facial sensation intact.

– CN VII: Facial movement symmetrical and without weakness.

– CN VIII: Hearing grossly intact to whispered voice bilaterally.

– CN IX, X, XII: Swallowing and gag reflex intact. Uvula midline and elevates with phonation. Tongue movement intact.

– CN XI: Shoulder shrug intact.

Cerebellar: No pronator drift. Gait normal with no ataxia. Coordination by RAM and point to point intact.

Extremities/Peripheral Vascular : Bilateral upper and lower extremities symmetric in color, size, and temperature. Pulses are 2+ bilaterally in upper extremities when palpating radial pulse. DP 2+ bilaterally. PT 2+ bilaterally. No clubbing, cyanosis, stasis changes or ulcerations in bilateral upper and lower extremities.

Assessment:

JS is a 76yo Female with PMH COPD on 2L Home O2, HTN, HLD, DM2, HFpEF, CKD IV, Vitamin D Deficiency with recent admission to QHC spanning 10/11/2019-10/16/2019 s/p syncopal episode being re-admitted to Margaret Tietz Nursing and Rehabilitation Center for restorative therapies. She has no acute complaints at this time.

#HTN, HFpEF, CKDIV – Stable

– Cont. ASA 81 mg chewable tab, 1 tab PO qd

– Cont. Amlodipine 10mg tab, 1 tab PO qd

– Cont. Carvedilol 25mg tab, take 1 tab PO bid

– Cont. Hydralazine 25mg tab, take 3 tab PO tid

– Cont. Isosorbide dinitrate 5mg tab, take 1 tab PO q8h

 

#DM2 – Stable

– Cont. Metformin ER 500mg tab, take 1 tab PO bid

 

#COPD – Stable

– Cont. O2 2L NC

– Cont. Albuterol 108 (90 base) mcg/act inhaler, inhale 2 puffs bid

– Cont. Budesonide-formoterol 80-4.5 mcg/act inhaler, inhale 2 puffs bid

– Cont. Ipratropium-albuterol 0.5-2.5mg/3mL nebulizer, take 3mL by nebulization q6h

– Cont. Sodium chloride 3% nebulizer solution, take 4mL nebulizer bid

 

#HLD – Stable

– Cont. Atorvastatin 20mg tab, 1 tab PO qhs

 

#Vitamin D Deficiency – Improving

– Cont. Cholecalciferol 1000u tab, take 1 tab PO qd

 

DVT Prophylaxis: Intermittent Pneumatic Compression

 

Nutrition: DASH Diet, Low Glycemic Diet

Disposition: Patient will require continued PT/OT to return to previous baseline level of functioning. Will likely require minimum 1wk stay. Social worker to discuss discharge planning with patient.

/s/ Daniel DeMarco, PA-S

Physician Assistant Student