css.php

HPI #1

HPI A.J. NY Presbyterian 10/22/2019

Identifying data:

Name: A.J.

Sex: F              Race: Latina             Religion: Did not disclose               Age: 62

Nationality: US                                 Marital status: separated

Time: 9:10am

History source: self

Referral source: self

PCD: Dr. Kazi K Haider (718 ) 886 03 55

Reliability: reliable

Transportation: ambulance

 Chief complaint: “Couldn’t breath well, had water in my lungs” * 6 days

    Ms. A.S. is a reliable 62 y/o  separated Latina female, with a significant part medical history of smoking, cardiovascular disease, Asthma,  diabetes, HTN, acute kidney injury , depression and anxious panic disorder presented to the ED with dyspnea and shortness of breath *6 days. Patient was admitted  3 day ago to IM floor. States she woke up with her ankles swollen more than usual 6 days ago accompanied with a mild shortness of breath. Over the course of the following three days symptoms worsened until dyspnea prevented her from being able to breath and that is when her daughter called 911 early morning 3 days ago. The symptoms came in sets, each lasted about 5 to 10 minutes. She used her Albuterol inhaler but it did not help. After being admitted to the hospital, she was administered a Lozol IV which alleviated the dyspnea symptoms. Admits to Cough with white thick mucus expectoration but no hemoptysis, wheezing, ortopnea needing 5 pillows  and PND. Admits to palpitations, irregular heartbeat, edema of the ankles. Denies cyanosis, chest pain, syncope or a known heart murmur. Patient states her disease put her on disability, she can not work and is afraid she is going to die. Pt states she has experienced a similar situation exactly one year ago.  

Past Medical History:

1970 – Rheumatic fever * 3yrs in L.I.C. Hospital

1970-current – Anxious Panic Disorder, Depression

1995 – current – Asthma

11/2006 – kidney stones (flushed)

2006 – polymyalgia rheumatica

2008 – ministroke – transient Ischemic attack

2010 – mass in left breast, diagnosed as benign

2012 – battery replacement on pacemaker

01/2014 – Mild heart attack, Asthma and Pneumonia

2018 – Aortic valve clogged due to congestive Heart Failure

Past Surgical History:

1997 – right knee surgery (Booth Memorial)

1997 – hysterectomy and oophorectomy due to cancer

7/22/2006 – Open Heart Surgery, Aortic and Mitral Valve replacement

11/2006 – pacemaker installation due to flatline

2007 – Appendectomy (Booth Memorial)

2010 – laparoscopic ventral hernia repair, mesh placed

2013 – replaced pacemaker due to a disconnected wire

Medications: At the hospital patient received an emergency course of treatment to which I could not obtain access

Allergies : NKDA

Family History:

Mother – deceased age 76, HTN, Heart attack

Father – 76 y.o., asthma, heart disease

Son – 36 y.o. HTN since age of 16

Son – 37, alive and well

Daughters – 42 and 39, alive and well

7 grandchildren, alive and well

Social History:

Ms. A is a separated female, living with her 19 y.o. granddaughter. She is on a disability but used to work for a cable company in a sales department.

Habits – does not drink but smokes on average a pack a day although admits a desire to quit. She stated she cut down to five cigarettes a day for the last few months.  She likes to drink coffee and has it once or twice a week.

Travel – did not travel anywhere recently

Diet – admits to not eating healthy, consuming foods high in sodium, and confectionery with high fructose corn syrup, even though she is diabetic.

Exercise – does not exercise

Sleep – sleeps on average 5 hours a day due to nocturia and PND, takes small naps throughput a day.

Safety measures – denies

Sexual Hx: not sexually active since her separation with her husband in 2005.

Leave a Reply

Your email address will not be published. Required fields are marked *

This site uses Akismet to reduce spam. Learn how your comment data is processed.