Identification
Full Name: P.N.
DOB: 3/15/1951
Date & Time: 11/8/2022 10:20AM Location: NYPQH
CC: “Trouble breathing” x 7 days
History of Present Illness
71 y/o male with Past medical history significant for HTN, BPH, Aortic valve disease,COPD s/p TAVR (11/1/2022) presents with dyspnea that started 7 days ago. Pt notes he was leaving his follow up pulmonologist appointment and started to feel SOB acutely within 30 minutes. Pt notes dyspnea worsens with exertion. Pt notes dyspnea was 8/10, which his wife then called a taxi for him. Pt notes dyspnea is now 3/10 and feels better. Pt denies known complications from TAVR. Pt usually walks a couple of blocks with his wife but notes the past 2 weeks he gets SOB quicker. Pt notes hx of similar symptoms but usually not this abrupt. Pt denies chest pain, syncope, nausea, vomiting.
Past Medical History:
HTN – 15 years
COPD – 11 years
AF – 6 years
Aortic Valve Disease – 3 months
Immunizations:
Medications:
Source Of Information: Self
Language: English
Reliability: Reliable
Mode of Transport: Driven by taxi
COVID – pt received 2nd pfizer booster in March 2022
Influenza – Last vaccine 1 year ago
Pneumonia – Last vaccine age 69
Albuterol – 2.5mg/3ml Nebulization, Q6H – Last dose: 8pm yesterday. Reason: COPD
Amiodarone – 200mg, QD, PO – Last dose: This morning. Reason: A- fib
Apixaban – 5mg, Q12H,PO – Last dose: This morning. Reason: A-Fib
Aspirin – 81mg, QD, PO – Last dose: this morning Reason: Anticoagulant therapy
Ipratropium 0.02%, Nebulizer solution 2.5mL – Q6H, Reason: COPD
Metoprolol tartrate – tartrate 50mg, Q12H, Reason: HTN
Allergies:
No known drug allergies
Family History
Mother: Deceased 82 y/o, reason unknown
Father: deceased, 84 y/o, reason unknown
Grandmother: decreased, age of death unknown reason unknown
Grandfather: deceased, age of death unknown reason unknown
Pt denies siblings
Pt denies children
Social History
Pt denies alcohol use, has not drank in over 10 years
Pt’s diet consists of rice, vegetables and meat cooked by his wife
Pt notes he is not sexually active, denied to further specify
Pt notes 7-8 hours of sleep per night
Pt is retired construction worker
Pt notes 1 mug of coffee per day
Pt smoked 1ppd but has not smoked in 10 years
Pt usually walks for a “couple” blocks with his wife
Denies illicit drug use
Denies recent travel
Review of Systems
General
: Pt notes generalized fatigue since onset of symptoms. Pt been feeling fatigued since onset
of symptoms. Pt notes fatigue is constant. Pt rates fatigue 7/10. Alleviating factors are rest and
Exacerbating factors are physical activity. Denies recent weight loss or gain, loss of appetite,, fever,
chills, or night sweats
Skin, Hair, nails:
Pt denies change in texture, excessive dryness or sweating, discolorations,
pigmentations, moles/rashes, pruritus, changes in hair distribution
Head: denies headache, vertigo, head trauma, LOC Eyes
Ears – denies deafness, pain, discharge, tinnitus, or hearing aids
Neck: denies localized swelling/lumps, stiffness/decreased range of motion.
: denies visual disturbance, blurring, diplopia, fatigue with use of eyes, scotoma, halos,
lacrimation, photophobia, priuitis, last eye exam 1 year ago, pt does not wear glasses.
|
Nose/sinus |
– denies discharge, epistaxis, obstruction |
Mouth and throat:
denies bleeding gums, sore tongue, sore throat, mouth ulcers, voice changes,
dentures. Pt notes good dental hygiene.
Pulmonary System:
syncope or known heart murmur
Pt notes 7/10 dyspnea that worsens with physical activity and is alleviated by
rest. Pt notes it is accompanied with wheezing that is 7/10. Pt notes it also worsens with physical
activity and is alleviated by rest. Pt denies hemoptysis, cyanosis, paroxysmal nocturnal dyspnea
Cardiovascular System:
Pt denies chest pain, palpitations, edema/swelling of ankles or feet,
Genitourinary System:
pt denies frequency, nocturia, urgency, oliguria, polyuria, dysuria, color of
urine: yellow, Denies incontinence, awakening at night to urinate or flank pain
Nervous System:
pt denies seizures, headache, LOC, sensory disturbances, ataxia, loss of
strength, change in cognition/ mental status/memory, weakness.
|
Musculoskeletal system: |
denies muscle/joint pain, deformity or swelling, redness. |
Peripheral Vascular System:
varicose veins, peripheral edema, or color change.
Denies intermittent claudication, coldness or tropic changes,
Hematologic system:
denies anemia, easy bruising or bleeding, lymph node enlargement, blood
transfusions, hx of DVT/pe
|
Endocrine System: |
denies polyuria, heat or cold intolerance, goiter, excessive sweating, hirsutism |
Psychiatric System
– pt denies depression/sadness, anxiety, obsessive/compulsive disorder. Pt
has never seen a mental health professional and is not taking psychiatric medications.
Physical Examination Vitals Signs
BP: Right arm- Seated: 136/82.
Left arm – Seated: 130/82. Supine: (136/80)
Supine: (132/80)
HR: 84 bpm, regular rate and rhythm
RR:18 breaths per minute, slightly labored
SpO2: 99% on 2L oxygen
Temp: 98.7 orally
Height: 68 inches
Weight: 121 pounds
BMI: 18.4
General:
Pt appears to be in slight discomfort. Alert and oriented x 3, Appears stated weight and
age, neatly groomed.
Head and Hair:
The head is normocephalic and atraumatic without tenderness, visible or palpable
masses, depressions, or scarring. Hair is of normal texture and evenly distributed.
Skin: Skin is warm, dry, and intact without rashes or lesions. Appropriate color for ethnicity.
Eyes
Ears:
Nose
Lips
Teeth – Good dentition / no obvious dental caries noted.
Neck
Chest
Heart
: Symmetrical OU, no strabismus, no exophthalmos, sclera is white, cornea clear, and
conjunctiva is pink.
Visual Acuity: 20/40 OS, 20/40 OD, 20/40 OU on Snellen chart – non corrected
Visual field: PERRL, EOM
Fundoscopy: Red reflex intact OU. Cup to disk ratio< 0.5 OU. No AV nicking, hemorrhages, or
exudates
– Symmetrical and appropriate in size. No lesions/masses / trauma on external ears. No
discharge / foreign bodies in external auditory canals AU. TM’s pearly white / intact with light reflex in
at 7 o’clock position on right, and 5 o’clock position on left Auditory acuity intact to whispered voice
AU. Weber midline / Rinne reveals AC>BC AU.
– Symmetrical / no masses / lesions / deformities / trauma / discharge. Nares patent
bilaterally / Nasal mucosa pink & well hydrated. No discharge noted on anterior rhinoscopy.
Septum midline without lesions / deformities / injection / perforation. No foreign bodies.
Sinuses
– Non tender to palpation and percussion over bilateral frontal, ethmoid and maxillary
sinuses.
– Pink, moist; no cyanosis or lesions. Non-tender to palpation.
Mucosa – Pink; well hydrated. No masses: lesions noted. Non-tender to palpation. No leukoplakia.
Palate
– Pink; well hydrated. Palate intact with no lesions; masses; or scars. Non-tender to
Palpation; continuity intact.
Gingivae
Palpation.
– Pink; moist. No hyperplasia; masses; lesions; erythema or discharge. Non-tender to
|
Tongue |
– Pink; well papillated; no masses, lesions or deviation. Non-tender to palpation. |
– Trachea midline. No masses; lesions; scars; pulsations noted. Supple; non-tender to
palpation. FROM; no stridor noted. 2+ Carotid pulses, no thrills; bruits noted bilaterally, no
cervical adenopathy noted.
|
Thyroid |
– Non-tender; no palpable masses; no thyromegaly; no bruits noted. |
– Symmetrical, no deformities, no trauma. Respirations unlabored / no Paradoxical
respirations or use of accessory muscles noted. Lat to AP diameter 2:1. Non-tender to palpation
Throughout.
: JVP is 2.5 cm above the sternal angle with the head of the bed at 30°. PMI in 5th ICS in mid-
clavicular line. Carotid pulses are 2+ bilaterally without bruits. RRR, S1 and S2 are distinct with no
murmurs, S3 or S4
Lungs
– B/L wheezing in all lungs fields. Chest expansion and diaphragmatic excursion
symmetrical. Tactile fremitus symmetric throughout.
|
Abdomen |
– flat and symmetric with no scars, striae or pulsations noted. Bowel sounds |
normoactive in all four quadrants with no aortic/renal/iliac or femoral bruits. Non-tender to palpation
and tympanic throughout, no guarding or rebound noted. Tympanic throughout, no
hepatosplenomegaly to palpation, no CVA tenderness appreciated.
Genitalia and Hernias:
Sensory
– Circumcised male. No penile discharge or lesions. No scrotal
swelling or discoloration. Testes Descended bilaterally, smooth and without masses.
Epididymis nontender. No inguinal or femoral hernias noted.
Anus, Rectum, and Prostate
– No perirectal lesions or fissures. External sphincter tone
intact. Rectal vault without masses. Prostate smooth and non-tender with palpable
median sulcus
Did not perform motor/cerebellar reflexes due to patient discomfort and patient was receiving
oxygen.
Motor/Cerebellar
Full active/passive ROM of all extremities without rigidity or spasticity. Symmetric muscle bulk with
good tone. No atrophy, tics, tremors or fasciculation. Strength 5/5 throughout. Rhomberg
negative, no pronator drift noted. Gait steady with no ataxia. Tandem walking and hopping show
balance intact. Coordination by rapid alternating movement and point to point intact bilaterally, no
asterixis
Intact to light touch, sharp/dull, and vibratory sense throughout. Proprioception, point localization,
extinction, stereognosis, and graphesthesia intact bilaterally
Reflexes
2+ throughout, negative Babinski, no clonus appreciated
(If abnormal reflexes present document fully as follows)
|
RL RL |
Brachioradialis 2+ 2+ Patellar 2+ 2+
Triceps 2+ 2+ Achilles 2+ 2+
Biceps 2+ 2+ Babinski neg neg
Abdominal 2+/2+ 2+/2+ Clonus negative
Meningeal Signs
No nuchal rigidity noted. Brudzinski’s and Kernig’s signs negative
Assessment
71 y/o male with PMH of HTN, BPH, Aortic valve disease,COPD s/p TAVR (11/1/2022) presents with dyspnea that started 7 days ago.
Pulmonary Embolism
– Elderly patient with sudden SOB and wheezing with recent aortic valve
replacement.
Plan: Assess Clinical features with Wells Criteria. Chest x-ray to look for abnormalities such as
pleural effusion or atelectasis. Oxygen therapy to maintain Sp02 over 90%. Anticoagulation such as
enoxaparin 1mg/Kg SC q12h. Continue to watch patient until recovery. Admit to ICU if oxygen drops
below 90%
ACS –
COPD exacerbation – Pt is a former smoker (1ppd 10 years ago) and complains of SOB.
Plan: Pulmonary function tests, Chest x-ray, Chest CT scan, Arterial blood gas. Pt may need increased albuterol and ipratropium doses to manage his SOB. If pt has difficulty adhering to medications he may be prescribed combination inhaler such as Breo (fluticasone and vilanterol) assuming insurance covers the medication. Another option is to use Phosphodiesterase-4 inhibitors if pt is not responding well to previous mentioned treatment .
Spontaneous Pneumothorax – Elderly pt, former smoker and is having SOB.
Plan: chest x-ray, CT of chest. Supplemental oxygen with a non-rebreather mask. If pt becomes unstable, needle decompression followed by chest tube insertion. If stable pt, can do watchful waiting and do serial x-rays every 4 hours.
Lung CA – Elderly pt, former smoker and is having SOB.
Plan: Chest x-ray to look for abnormal mass or nodule. CT scan to look for smaller masses. Sputum Cytology to detect cancer cells. Tissue sample of possible abnormal cells. If cancer has been diagnosed, pt will need to be referred to an oncologist to determine the stage and assess for possible metastasis. Pt may also be evaluated for other treatments such as surgery, radiation therapy, or chemotherapy.
I would work this patient up for a COPD exacerbation and try to change his medication regimen. I would also look up previous medical records to see if there was any complication during the TAVR.
