Assignment: History and Physical Note

Assignment: History and Physical Note

Assignment: History and Physical Note

Hospitalist Consult

Chief Complaint or Reason for Consult:“I am short of breath and very weak”.

History of Present Illness (HPI):

R.F. is a 90-year-old Caucasian female with a past medical history of CHF, CAD, Afib, HTN, HLD, former smoker, and hypothyroidism who presents to the ED with shortness of breath and weakness for two days. R.F. reports feeling very tired, loss of appetite and a productive cough recently. She has been coughing up clear sputum. R.F. also reports having a fever over the last two days. She resides at an assisted living facility. R.F. O2 satsin the ED were noted to 90% on RA. Currently R.F. O2 sats are 94-97% on RA. Chest X-ray shows bilateral pleural effusions with atelectasis. R.F.tested positive for COVID 19today and has a WBC of 13.0. Her BNP is currently 3,040.

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Past Medical History:

• CHF
• CAD
• Afib
• HTN
• HLD
• Hypothyroidism
• Former smoker
• PAD
• GERD
• Depression
• Anxiety
• IBS
• Chronic back pain

Past Surgical History:

• Cardioversion 10/31/2022
• TEE 10/31/2022
• EP study and dual chamber AICD insertion 4/5/2021
• Bilateral iliac angiogram intervention with aortoilial stent graft 10/16/2020
• Cardiac catheterization/Left heart catheterization 4/4/2018
• Cataract extraction 2010
• Replacement total knee-right 1998
• Partial hysterectomy 1970
• Bladder surgery 1952
• Cholecystectomy 1952

Family History:

Son:Alive, 65 y/o,Hypertension

Daughter: Alive, 58 y/o, Diabetes Mellitus Type 2

Mother: Deceased, 88 y/o, Smoker, Lung Cancer

Father: Deceased, 80 y/o, Diabetes Mellitus 2, Hypertension

Paternal Grandfather: Deceased, 83 y/o,stroke

Paternal Grandmother: Deceased, 75, y/o, breast cancer

Maternal Grandmother: Deceased, 84 y/o, Hypertension, MI

Maternal Grandfather: Deceased, 89 y/o, COPD, Smoker

Social History:R.F. is a widow who lives in an apartment at Thunderbird Senior Living who has help from her family which include her son and daughter. Her son and daughter both help participate in R.F. care by transporting her to her scheduled appointments for follow up care with her specialty doctors. R.F. follows a cardiologist and electrophysiologist due to her extensive cardiac history in the outpatient setting. R.F. was a former smoker who quit 25 years ago. She denies any alcohol or illicit drug use. R.F. senior living provides all meals for her, but she reports a decrease in her appetite lately which has consisted of juice, water, and crackers. She currently has health insurance. R.F. has an advanced directive which states she wishes to be DNR/DNI which will be ordered for hospital stay which was discussed with her son and daughter.

Allergies:

• Clindamycin Hives
• Doxycycline Hives
• Sulfa Rash
• PCN Rash

Home Medications:

• Amiodarone 100 mg PO daily
• Cogentin 0.5 mg PO daily
• Wellbutrin XL 150 mg PO daily
• Cymbalta 60 mg PO daily
• Flonase 1 spray to each nostril BID
• Synthroid 75 mcg PO daily at 6 AM
• Metoprolol succinate 100 mg PO daily
• Nitrostat 0.4 mg SL tablet Q5min PRN
• Oxycodone IR 10 mg PO Q6H PRN
• Protonix 40 mg PO daily
• Pilocarpine 5 mg PO TID
• Pravastatin 40 mg PO QHS
• Xarelto 20 mg PO QPM
• Senna 8.6 mg PO daily
• Linaclotide 145 mcg PO daily
• Valsartan 40 mg PO daily

Hospital Medications:

• Amiodarone 100 mg PO daily
• Atorvastatin 10 mg PO QHS
• Tessalon capsule 100 mg PO Q8H
• Cogentin 0.5 mg PO daily
• Wellbutrin XL 150 mg PO daily
• Decadron6mg IV Q24H
• Cymbalta 60 mg PO daily
• Flonase 50MCG/ACT nasal spray; 1 spray each nostril BID
• Lasix 20 mg PO Q24H
• Synthroid 75 mcg PO daily
• Metoprolol Succinate 100 mg PO Q24H
• Protonix 40 mg PO Q24H
• Pilocarpine 5 mg PO TID
• Mirlax 17g packet PO Q24H
• Remdesivir 100 mg IV daily
• Xarelto 15 mg PO QPM
• Senna 8.6 mg PO daily
• Valsartan 40 mg Q24H
• Tylenol 650 mg Q6H PRN
• Klonopin 0.5 mg PO BID PRN
• Narcan 0.4 mg SL Q5min PRN
• Zofran 4mg IV Q6H PRN
• Oxycodone IR 10 mg PO Q6H

Review of Systems:

• CONSTITUTIONAL: Positive energy levels. Positive fever. Denies chills or significant weight changes.
• EYES: Denies vision changes, eye pain, or double vision.
• EARS, NOSE, and THROAT: Denies hearing loss, tinnitus, ear discharge, facial pain, sneezing, rhinorrhea, throat pain, hoarse voice, sore tongue, or bleeding gums.
• CARDIOVASCULAR:Positive for SOB. Negative for chest pain or palpitations.
• RESPIRATORY:Positive for SOB, productive cough and sputum production. Negative for chest tightness and wheezing.
• GASTROINTESTINAL: Denies epigastric/abdominal pain, flatulence, bloating, diarrhea, constipation, or tarry stools.
• GENITOURINARY: Denies dysuria, penile discharge, increased urination, or urinary urgency or frequency.
• MUSCULOSKELETAL: Denies joint pain, stiffness, muscle cramps.
• INTEGUMENTARY: Denies bruises or any other skin changes.
• NEUROLOGICAL: Negative for dizziness, headache, and fainting. Positive for muscle weakness.
• PSYCHIATRIC: Denies having depressive symptoms. Positive for anxiety.
• ENDOCRINE: Denies heat/cold intolerance, acute thirst, or hunger.
• HEMATOLOGIC/LYMPHATIC: Denies bleeding, bruising, or lymph node enlargement.
• ALLERGIC/IMMUNOLOGIC: Negative for hives or allergies.

Physical Exam:

• GENERAL APPEARANCE: The patient is a 90-year-old female. She isalert, oriented x 4, and in no distress. She appears anxious, but she maintains eye contact and has clear and coherent speech.
• VITAL SIGNS: BP- 128/99; HR- 73; RR-19; Temp: 100.5; Sp02-95 RA; Wt-128 lbs; Ht-5’6; BMI- 20.7
• HEENT: Head: Normocephalic and symmetrical. Eyes: Sclera is white and conjunctiva pink; No excessive lacrimation; PERRLA. Ears: Tympanic membranes are shiny and intact. Nose: No nasal secretions or bleeding; The nasal septum is well-aligned. Mouth & Throat: Pink and moist mucous membranes; Tonsillar glands are non-erythematous.
• NECK: Full neck ROM. The trachea is midline and well-aligned.
• CHEST: Nontender to palpation.
• LUNGS: Breath sounds are equal and clear/diminished bilaterally. No wheezes, rhonchi, or rales.
• HEART: Regular rate and rhythm with normal S1 and S2. No murmurs, gallops, or rubs.
• BREASTS: No nipple discharge, breast tenderness, or mass.
• ABDOMEN: Abdomen is rounded, soft with no distension or scars; Normoactive BS in all quadrants. No epigastric or abdominal tenderness or organomegaly.
• GENITOURINARY: No urinary pain or discharge.
• RECTAL: Normal sphincter tone. No masses or tenderness.
• EXTREMITIES: Full ROM in extremities. Nojoint stiffness or enlargement.
• NEUROLOGIC: Normal gait and posture. Muscle strength 4/5in extremities.
• PSYCHIATRIC: Anxiety noted. No depressive symptoms noted. Logical and goal-directed thought content and process.
• SKIN: Warm and dry.
• LYMPHATICS: Lymph nodes are non-palpable.

Laboratory and Radiology Results:

12/06/22

CBC

WBC                                                   13.0

RBC                                                    4.67

Hgb                                                     11.4

HCT                                                    38.0

MCV                                                   81.4

MCH                                                   24.4

MCHC                                                30.0

RDW-SD                                            54.9

RDW-CV                                            19.1

Platelets                                               414

MVP                                                   11.9

Lymphs                                               9

Lymphocytes Absolute                       1.15

Monocytes                                          6

Monocyte Absolute                            0.75

Eosinophils                                          0

Eosinophils Absolute                          <0.05

Basophils                                             0

Basophils Absolute                             <0.05

Neutrophils                                         85

Neutrophils Absolute                          11.05

Immature Grans                                  0

Immature Grans Absolute                   0.04

Nucleated RBC Absolute                   0.000

nRBC                                                  <1.0

PT                                                        13.0

INR                                                     0.97

 

CMP

Glucose                                               121

BUN                                                   16

Creatinine                                            0.9

eGFR                                                  >60

Sodium                                                134

Potassium                                            4.8

Chloride                                              104

CO2                                                    26

Anion Gap                                          4

 

BNP                                                  3,040

 

COVID Swab PCRà                       Positive

X-ray Chestà                                   Bilateral pleural effusions with bibasilar atelectasis.

Differential Diagnosis:

COVID-COVID manifests with a wide range of clinical manifestations affecting HEENT, cardiovascular, respiratory, neurological, and GI systems. The symptoms include headache, fever, cough, sore throat, malaise, nasal congestion, sneezing, hemoptysis, dyspnea, fatigue, sputum production, chest pain, rhinorrhea, palpitations, nausea, vomiting, abdominal pain, myalgia, and confusion (Da Rosa Mesquita et al., 2021).

Influenza-Influenza is a highly contagious acute viral respiratory infection that occurs in adults across the lifespan. Symptoms of influenza include severe headache, fever, chills, sore throat, cough, rhinorrhea, red-watery eyes, muscle aches, severe fatigue, and general body weakness (Phetcharakupt et al., 221). Patients also present with GI symptoms like nausea, vomiting, abdominal discomfort/pain, and diarrhea. Physical exam findings in influenza include high body temperatures (100-104°F), tachycardia, inflamed pharynx, warm to hot skin, dry cough with clear lungs or rhonchi, and focal wheezing.

Pneumonia- Pneumonia is caused by excessive fluid in the lungs due to an inflammatory process. Clinical manifestations of pneumonia include increased respiratory rate, dyspnea, cough, purulent, blood-tinged, or rust-colored sputum fever, pleuritic chest discomfort, chest pain aggravated by respiration and coughing, loss of appetite, low energy, and fatigue (Lim, 2020). Physical findings include hyperthermia, nasal flaring, use of accessory muscles of respiration, flushed cheeks, cyanosed lips and nail beds, unequal chest expansion, crackles on auscultation, wheezing, and bronchial breath sounds heard over areas of density.

Congestive heart failure exacerbation-Clinical symptoms of CHF exacerbation include exertional dyspnea, dyspnea at rest, orthopnea, chest pain, palpitations, fatigue, weakness, nocturia, oliguria, and edema (Schwinger, 2021). Physical findings include tachycardia, neck veins distention, weak, rapid, and thready pulse, rales, wheezing, S 3 gallop, hepatojugular reflux, ascites, and central or peripheral cyanosis.

Working Diagnosis:Acute hypoxic respiratory failure secondary to COVID-19          J96

Problem List

• Acute and Chronic Medical Conditions:

1. Acute hypoxic respiratory failure secondary to COVID 19 J96
2. Acute systolic CHF exacerbation with bilateral pleural effusions  2
3. Leukocytosis  829
4. Atrial fibrillation with left bundle branch block                                              7
5. Hypertension I10
6. Hypothyroidism E05
7. Hypercholesteremia              00
8. GERD 9
9. Irritable bowel syndrome 8
10. Depression 0
11. Anxiety 9
12. Chronic back pain 5
13. ICD (Implantable cardioverter-defibrillator) I25
14. Ischemic cardiomyopathy              5
15. Coronary artery disease without angina 10
16. Peripheral vascular disease 9

TreatmentPlan:        

• Supplemental O2 prn to keep O2 sats>92%, sats in ED were 90%
• Decadron 6 mg IV Q24H and remdesivir 100 mg IV daily. Decandron is a corticosteroid used for its anti-inflammatory and immunosuppressant effects. NIH guidelines for COVID-19 treatment recommend the use of dexamethasone (Decandron) to lower mortality in hospitalized patients who are mechanically ventilated or those requiring supplemental oxygen without mechanical ventilation (Panel et al., 2020). Remdesivir has demonstrated in vitro and in vivo activity against SARS-CoV-2. It retains in vitro neutralization activity against the Omicron variant and its subvariants. Remdesivir was the first antiviral drug approved by the FDA for management of COVID-19 (Panel et al., 2020).
• Tessalon pearls 100 mg TID, to relieve cough. It has been found to ease cough in most patients with COVID-19.
• SVNs prn. Nebulization is indicated for bronchodilation to relieve airflow obstruction.
• Isolation precautions
• Infectious disease consult
• Cardiology consulted
• Lasix 20 mg IV x 1 dose now then PO daily, not on diuretics outpatient. Lasix will be administered to treat fluid retention and relieve CHF symptoms caused by excess fluid overload.
• EF 40% in October 2022
• BNP 3,040
• Resume home meds Metoprolol Succinate 100mg PO daily, and Valsartan 40 mg PO daily
• Low Na diet. A low sodium diet is recommended to promote optimal blood pressure.
• Daily weights. This will help to monitor fluid overload and will play a vital role in CHF management since it will allow the therapeutic efficacy of diuretic therapy to be maximized (Al-Refaie & Taylor, 2021).
• Strict I/Os. Monitoring input and output will be crucial to assess hydration status and if the patient has fluid overload, which is a common symptom in CHF(Al-Refaie & Taylor, 2021).
• Monitor WBC, WBC 13.0 today
• Daily labs CBC and CMP
• UA
• Resume home med Amiodarone 100 mg PO daily
• Resume home med Nitro tab SL 0.4 mg PRN
• Xarelto 15 mg PO QPM
• Resume home med Synthroid 75 mg PO daily in AM
• Resume home med Pravastatin 40 mg PO QHS
• Resume home med Protonix 40 mg PO daily
• Zofran 4 mg IV Q6H PRN
• Resume Senna 8.6 mg PO daily
• Mirlax 17 gm PO daily
• Resume home meds Wellbutrin XL 150 mg PO daily and Cymbalta 60 mg PO daily
• Resume home med Oxycodone IR 10 mg Q6H PRN
• Tylenol 650 mg Q6H PRN
• Klonopin 0.5 mg PO BID PRN

The expected treatment outcomes include improved airway clearance, breathing pattern, and ablation of underlying respiratory infection.

Health Education:

The patient and the family will be educated on prevention of COVID including handwashing with soap and water for at least 20 seconds. They will also be advised to use an alcohol-based hand sanitizer if soap and water are unavailable. The patient will be advised to avoid touching her eyes, nose, and mouth with unwashed hands. Besides, the patient will be advised to stay at home until the COVID symptoms abate (WHO, 2022). In addition, she will be advised to cover coughs and sneezes with a tissue and dispose of the tissue in trash. Health promotion during discharge will focus on diet. The patient will be educated on taking a balanced diet with plenty of vegetables and fruits to boost her immunity.

Consultations:

13. Infectious diseaseà LeukocytosisàWBC 13.0 & COVID 19 +
14. CardiologyàHx of CHFà Chest X-Rayà bilateral pleural effusions with bibasilar atelectasis

Follow-up: The patient will be followed-up two weeks after discharge to assess progress with treatment.

Geriatric or Ethical Considerations:

The WHO (2022) clinical guidelines recommend a review of medication prescriptions in geriatric patients to reduce polypharmacy and prevent drug interactions and adverse events for older adults being treated with COVID-19. Ethical considerations for this case include principles of beneficence and nonmaleficence. The clinician should consider the best practice in treatment of elderly patients with Acute hypoxic respiratory failure secondary to COVID. Thus, treatment interventions associated with best outcomes and least or no side effects should be considered in this patient case (Brown et al., 2020). The patient’s religious beliefs may influence her adherence to treatment and her confidence with the treatment interventions. Some religious practices may hinder her from adhering to recommended health interventions like the belief that her Creator will heal her.

References

Al-Refaie, N., & Taylor, L. (2021). 147 Daily weight and fluid balance assessment in patients admitted with acute heart failure.

Brown, R., McKelvey, M. C., Ryan, S., Creane, S., Linden, D., Kidney, J. C., … & Weldon, S. (2020). The impact of aging in acute respiratory distress syndrome: a clinical and mechanistic overview. Frontiers in Medicine, 7, 589553.

Da Rosa Mesquita, R., Francelino Silva Junior, L. C., Santos Santana, F. M., Farias de Oliveira,

 

T., Campos Alcântara, R., Monteiro Arnozo, G., … & Freire de Souza, C. D. (2021).

Clinical manifestations of COVID-19 in the general population: systematic

review. Wiener klinischeWochenschrift, 133(7), 377-382.doi: 10.1007/s00508-020-

01760-4

Epocrates mobile app (2022).

Lim, W. S. (2020). Pneumonia—Overview. Reference Module in Biomedical Sciences, B978-0-

12-801238-3.11636-8. https://doi.org/10.1016/B978-0-12-801238-3.11636-8

Panel, C. T. G. (2020). Coronavirus disease 2019 (COVID-19) treatment guidelines. Health NIo, editor: In. https://www.covid19treatmentguidelines.nih.gov/.

Phetcharakupt, V., Pasomsub, E., &Kiertiburanakul, S. (2021). Clinical manifestations of

influenza and performance of rapid influenza diagnostic test: A university hospital

setting. Health science reports, 4(4), e408. https://doi.org/10.1002/hsr2.408

Schwinger, R. H. G. (2021). Pathophysiology of heart failure. Cardiovascular diagnosis

            and therapy, 11(1), 263–276. https://doi.org/10.21037/cdt-20-302

World Health Organization. (2022). Clinical management of COVID-19: living guideline, 15 September 2022 (No. WHO/2019-nCoV/Clinical/2022.2). World Health Organization.