Identifying Data:

Name: Mr. H

Sex: Male

Address: Long Island, NY

Date of Birth: 8/27/1927, 93 years old

Date & Time: 5/03/21, 9:30 AM

Location: Northshore University Hospital, Manhasset, NY

Religion: Christian

Marital Status: Widowed

Race: Caucasian

Source of Information: Self

Reliability: Reliable

Source of Referral: Dr. Patrick Wu, PCP

Mode of Transport: Ambulance

Chief Complaint: “I am breathing heavy” x 2 weeks

History of Present Illness:

93 year old widowed male w/ pmhx AFib on eliquis, CAD, HLD, HTN, MVP, and prostate CA presents from the PMD office via ambulance to ER on 05/01/21 for 2 weeks of worsening lower extremity edema with associated exertional SOB. He stated that 2 weeks ago, he felt his legs beginning to swell, and it has been gradually getting worse. He also noticed that his breathing was becoming more difficult, especially when he attempted to walk around. He is usually able to walk for about 10-15 minutes without difficulty, and now felt short of breath when walking just a few steps, and even when speaking. He states that he did not take any medications for his symptoms, and sitting up in bed made the SOB better, but nothing really made the leg edema better or worse. He went to his PCP, Dr. Wu, due to his symptoms, who sent him to the ER for further evaluation. Patient denies hemoptysis, history of DVT/PE, chest pain or other pain, palpitations, weakness/fatigue, headache, fever, dizziness, cough or wheezing.

Upon examination in ED, patient was found to have 3+ bilateral edema and an O2 sat of 87% on room air, for which he was put on 2L NC, and his O2 sat came up to 96% Patient was given Lasix 40 mg IVP and began a salt and fluid restriction diet. The patient was also noted to have Serum Na level 129. Pt takes prescribed HCTZ but was discontinued as recommendations for hyponatremia.

Chest xray impression shows “Cardiomegaly. Mild right pleural effusion with associated right basilar atelectasis.” EKG showed A-Fib at a ventricular rate of 88.

Currently, on 5/03/21, patient states that he is feeling much better and is able to walk around without feeling short of breath. He also states that he feels the swelling in his legs improving.

Past Medical History:

Present medical illnesses – Afib, CAD, HLD, HTN, Mitral Valve Prolapse

Past Illnesses- Testicular Cancer s/p surgical removal 35 years ago, Prostate Cancer s/p radiation 12 years ago

Childhood illnesses – none

Immunizations – Up to date

Screening Tests- none

Blood Transfusions- none

Past Surgical History:

Left Oorchiectomy, for Testicular Cancer 1985

Home Medications:

1. Hydrochlorothiazide, 12.5 mg oral daily, for HTN, MVP, on pause due to hyponatremia
2. Amlodipine Tablet 2.5 milliGRAM(s) Oral daily, for HTN/CAD
3. Losartan 25 milliGRAM(s) Oral daily, for HTN
4. Apixaban 2.5 milliGRAM(s) Oral two times a day, for Atrial Fibrillation
5. Atorvastatin 40 milliGRAM(s) Oral at bedtime, for HLD and CAD
6. Tamsulosin 0.4 milliGRAM(s) Oral at bedtime
7. Calcium carbonate 1250 mG  + Vitamin D (OsCal 500 + D) 1 Tablet(s) Oral daily, dietary supplement
8. Cyanocobalamin (B12) 1000 MICROGram(s) Oral daily, supplement
9. Folic acid 1 milliGRAM(s) Oral daily, supplement

Hospital Added Medications

1. Furosemide Injectable 40 milliGRAM(s) IV Push daily, for fluid
2. Melatonin 1 milliGRAM(s) Oral at bedtime, for sleep
3. Polyethylene glycol 3350 17 Gram(s) Oral daily, for constipation

Allergies:

No known food, drug, or environmental allergies.

Family History:

Mother – deceased at age 98, natural causes

Father – deceased at 76, Colon Cancer

Daughter- deceased at age 51 in a car accident

Daughter- Age 53, alive and well

Maternal/paternal grandparents – Deceased at unknown age and unknown reasons

Social History:

Mr. H is a 93 y/o widowed male, his wife died 20 years ago and he has been living with his partner for the past 12 years. He lives in a 2 story house, his daughter lives on the other floor. He is a retired tour guide.

Habits – Patient drinks one cup of green tea every morning. Admits to having 1-2 alcoholic drinks about every month. Denies smoking, use of e-cigarettes or any illicit drug use. 

Travel- Denies any recent travel.

Safety- Admits to wearing seat belt.

Sleep – Admits to sleeping well, for more than 8 hours every night.

Exercise – States that he walks a few blocks with walker every day for about 10-15 minutes

Diet- Patients maintains a balanced diet, with cereal in morning, tuna sandwich or pizza for lunch, noodles and vegetable for dinner. He also eats fruits throughout the day.

Sexual History: Monogamous, has single female partner. Currently sexually active. Denies history of sexually transmitted infections.

Patient has bilateral hearing aids, eye glasses, and dentures.

Patient had COVID Moderna Vaccine, one in January and second in early February

Review of Systems:

General – Denies loss of appetite, recent weight loss or gain, current generalized weakness, fatigue, fever, chills, or night sweats.

Skin, hair, nails –Denies changes in texture, excessive dryness or sweating, discolorations, pigmentations, moles/rashes, pruritus or changes in hair distribution.

Head – Denies dizziness, headaches, vertigo or head trauma, unconsciousness, head fracture or coma.

Eyes –Patients admits to use of glasses. Denies use of contacts, visual disturbances, fatigue, lacrimation, photophobia, and pruritus. Last eye exam last January- normal.

Ears –Admits to having bilateral hearing aids due to hearing loss for the past 15 years. Denies ear pain, discharge, or use of hearing aids.

Nose/sinuses – Denies discharge, obstruction or epistaxis.

Mouth/throat – Admits to use of dentures for the past 10 years. Denies sore throat, sore tongue, bleeding gums, mouth ulcers, voice changes. 

Neck – Denies localized swelling/lumps or stiffness/decreased range of motion

Breast- Denies lumps, nipple discharge, and pain.

Pulmonary system – Admits to slight but improving dyspnea on exertion. Denies dyspnea, shortness of breath, cough, wheezing, orthopnea, paroxysmal nocturnal dyspnea, cyanosis or hemoptysis.

Cardiovascular system –Admits to hypertension and edema/ swelling of the ankles/feet. Denies chest pain, palpitations, irregular heartbeat, syncope or known heart murmur.

Gastrointestinal system –Denies changes in appetite, intolerance to foods, abdominal pain, nausea, vomiting, diarrhea, constipation, dysphagia, pyrosis, flatulence, eructation, jaundice, hemorrhoids, rectal bleeding, or blood in stool. 

Genitourinary system –Admits to occasional nocturia. Deniesurinary frequency, urgency, polyuria, oliguria, nocturia, incontinence, dysuria, hesitancy, dribbling, or flank pain.

Musculoskeletal system –Denies muscle/joint pain, arthritis, deformity or swelling, or redness.

Nervous System–Denies seizures, loss of consciousness, ataxia, loss of strength, change in sensation/tingling/ numbness, change in cognition / mental status / memory, or asymmetric weakness.

Peripheral vascular system –  Admits to occasional peripheral edema. Denies intermittent claudication, coldness or trophic changes, varicose veins, or color changes.

Hematological system – Denies anemia, easy bruising or bleeding, lymph node enlargement, or history of DVT/PE.

Endocrine system –Denies polyuria, polyphagia, polydipsia, heat or cold intolerance, excessive sweating, hirsutism, or goiter.

Psychiatric –Denies depression, anxiety, OCD or ever seeing a mental health professional.

 Physical Exam

General: 93 year old male, alert and oriented to person, place and time. Patient is of average build and has good posture, is well dressed, well groomed, and has good hygiene. Patient appears in no apparent distress.

Vital Signs: BP: 116/51, supine                       

R: 18 breaths/min unlabored     

P:62 beats/min, regular       

T: 97.5 Degrees F (oral)                      

O2 Sat: 97% on Room air

Height: 66 inches                Weight: 154 pounds            BMI: 24.9

Skin- Warm and dry, smooth, poor turgor, nonicteric. No lesions, masses, scars, tattoos, thicknesses or opacities.

Hair- average quantity and distribution. Coarse, no lice or seborrhea noted.

Nails- Normal color size and shape of the nails. No spooning, clubbing, beau’s lines fissures, paronychia noted. Capillary refill <2 seconds throughout hands and toes.

Head-Atraumatic, normocephalic. Nontender to palpation on the frontal, temporal, occipital, and parietal areas. No deformities or specific faces noted.

Eyes-Symmetrical OU. Eyebrows and eyelashes even distribution, eyelids have no discharge or swelling, lacrimal glands have no excessive tearing, dryness, enlargement or erythema, lacrimal sac not inflamed or swollen. No evidence strabismus, exophthalmos or ptosis. Sclera white, conjunctiva and cornea clear.  Visual fields full OU. PERRL, EOMs intact with no nystagmus. 

Ears- Symmetrical and normal size. No lesions, masses or trauma on external ears. No discharge/foreign bodies in external auditory canals AU. Tympanic membrane pearly white/intact with cone of light in normal position AU. Auditory acuity intact upon whisper test.

Nose-Symmetrical, no masses lesions or deformities, trauma or discharge. Nares patent bilaterally, nasal mucosa pink & well hydrated. 

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

Mouth

Lips –Pink and moist,no cyanosis or lesions

Mucosa – Pink, well-hydrated, No masses; lesions noted. No leukoplakia.

Palate – Pink, well hydrated. Palate intact with no lesions; masses; scars. 

Teeth – wears dentures. Was not wearing them during examination.

Gingivae – Pink; moist. No hyperplasia; masses; lesions; erythema or discharge.

Tongue –Pink, well papillated; no masses, lesions or deviation noted.

Oropharynx – Well hydrated; no injection; exudate; masses; lesions; foreign bodies. Tonsils present with no injection or exudate. Uvula pink, no edema, lesions. 

Neck – Trachea midline. No masses; lesions; scars; pulsations noted. Supple; non-tender to palpation.   

Thyroid- Non-tender; no palpable masses; no thyromegaly; no bruits noted.

Thorax & Lungs 

Chest – Symmetrical, no deformities, no evidence of trauma. Respirations are unlabored, no paradoxical respirations or use of accessory muscles noted. Lat to AP diameter 2:1. Non- tender to palpation. 

Lungs – Some crackles noted upon auscultation at bilateral lung bases. Clear to percussion bilaterally. Chest expansion and diaphragmatic excursion symmetrical.

Abdomen-Abdomen flat and symmetric with no striae, scars or pulsations noted. Bowel sounds normoactive in all four quadrants with no aortic/renal/iliac or femoral bruits. Abdomen soft and non-tender to palpation across all 4 quadrants, no guarding or rebound noted. No hepatosplenomegaly to palpation, no CVA tenderness appreciated. 

Heart-Irregular rate and rhythm. S1 and S2 with soft systolic murmur at lower left sternal border. No splitting of S2 or friction rubs appreciated. Carotid pulses are 2+ bilaterally without bruits.

Male Genitalia- deferred

Anus, Rectum, and Prostate-deferred

Mental Status Exam- patient is alert, attentive, and oriented. Speech and language are clear and fluent with good word comprehension. Appears to be in good mood, has insight and judgment into  his medical problems. Memory and cognitive ability intact, gave accurate information upon assessment of history.

Cranial Nerve Exam – 

CNII-visual fields full by confrontation, red reflex present

CN III, IV, and VI- extraocular movements intact, PERRLA, no ptosis

CN V- face sensation intact bilaterally, corneal reflex intact, jaw muscles strong without atrophy

CN VII- facial expressions intact, clearly enunciates words

CN IX and X- no hoarseness, uvula midline with elevation of soft palate, gag reflex intact, no difficulty swallowing

CN XI- full range of motion at neck with 5/5 strength and strong shoulder shrug

CN XII- tongue midline without fasciculations, good tongue strength

Peripheral Nervous System-

Motor/Cerebellar-Full active/passive ROM of all extremities.. Symmetric muscle bulk, slight atrophy, no tics, tremors or fasciculation. Strength 4/5 throughout upper extremities, 5/5 on lower extremities bilaterally. Romberg negative, no pronator drift noted. Gait slightly unsteady, but steady with walker. Deferred tandem walking and hopping, because if unsteady without walker. Coordination by rapid alternating movement and point to point intact bilaterally, no asterixis.

Sensory-Intact to light touch, sharp/dull, and vibratory sense throughout.   Proprioception, point localization, extinction, stereognosis, and graphesthesia intact bilaterally.

Reflexes-2+ throughout.

Peripheral Vascular Exam- 2+ pitting edema bilaterally, equal in circumference, no calf tenderness. Skin normal in color and warm to touch upper and lower extremities bilaterally. . No palpable cords or varicose veins bilaterally. No palpable inguinal or epitrochlear adenopathy. No cyanosis, clubbing / edema noted bilaterally.

 Labs:

133<L>  |  97  |  22

—————————-<  89

3.8           |  22 |  1.17

Ca    9.5     

Phos  3.5

Mg     2.2    

Protein  6.7 

Alb  3.8 

TBili  1.3<H>  (normal up to 1.2)

AST  31 

ALT  15 

AlkPhos  76 

         11.1 L

4.86 )———–( 120 L  

           33.4 L

Imaging:

Chest X-ray- FINDINGS: Thoracic aortic atheromatous changes and ectasia are present.Heart is enlarged. Left lung is clear, with mild right pleural effusion with associated right basilar atelectasis. No pneumothorax.

IMPRESSION: Cardiomegaly and Mild right pleural effusion with associated right basilar atelectasis.

EKG– irregular rate and rhythm- A-fib, with average rate of 88.

Assessment

Mr. H is a 93 year old widowed male w/ pmhx AFib of eliquis, CAD, HLD, HTN, MVP, and prostate CA who presented from the PMD office via ambulance to ER on 05/01/21 for 2 weeks of worsening lower extremity edema with associated exertional SOB. He was admitted and treated with oxygen and Lasix and put on a salt and fluid restriction diet. His EKG showed A-fib, and CXR showed cardiomegaly and right pleural effusion and atelectasis. Currently, his edema and shortness of breath have improved, and he is awaiting a repeat CXR and echocardiogram.

Differential Diagnoses

1. CHF exacerbation/ fluid overload– patient has pleural effusion on CXR, lower extremity edema and shortness of breath, improved s/p Lasix and fluid and salt restriction.
2. Pulmonary Embolism– patient is complaining of shortness of breath, and has lower extremity edema so it can be a DVT which turned into a PE. Also has pleural effusion on CXR which could be a sign of PE. He has some risk factors for PE, including HTN and CAD, however they are well controlled, and he does not have other risk factors. Also, the symptoms were more gradual, and the lower extremity edema is bilateral, which makes it less likely to be a DVTà PE. D-dimer/ CTPA was not performed.
3. COPD– patient has lower extremity edema and SOB. However, no cough/wheezing, no history of COPD, so unlikely that he would get it at this age, and nonsmoker, not obese, so no real risk factors.
4. Pneumonia– patient has SOB and signs of one-sided pleural effusion/ atelectasis on CXR. However no fever or cough, WBC’s are not elevated.
5. Covid-19 – patient has SOB, however no other COVID symptoms, was not surrounded by anyone with COVID, and had both COVID vaccines.

Problem List/Plan  

1. Dyspnea on exertion/ lower extremity edema/ crackles on lung bases/ fluid overload– improving; continue IV Lasix and salt/fluid restriction 1L/day, obtain repeat CXR to ensure improvement, obtain TTE to look at left ventricular function and r/o structural heart disease. Consult with Cardiology. Weigh patient daily to ensure improvement.
2. Hyponatremia-Improving since admission (129) since HCTZ was discontinued, currently at 133- still low. Supplementing with sodium difficult due to fluid overload. Consult renal.
3. Low Hemoglobin and Hematocrit– currently at 11.1 and 33.4, so only slightly low, may be due to hemodilution due to fluid overload. Check RBC’s, MCV, MCH to r/o anemia. Trend H/H to ensure doesn’t decrease further.
4. Hypertension-BP well controlled, continue current medication
5. Atrial Fibrillation– rate is controlled on anticoagulation, continue current medication
6. CAD-TTE to ensure heart is pumping well, continue medications
7. HLD-obtain labs on lipids/ cholesterol to ensure well controlled. Continue current medications
8. Mitral Valve Prolapse– no acute issues, continue current medications