HPI R.V
Chief Complaint: “Unable to breath*5 hrs
Mr.V is a 82 y.o. male with a PMH of ESRD on HD, well controlled HTN and DM who missed his Dialysis for one day, presents to ED with c/o dyspnea*5 days. Mr.V’s dyspnea started this morning, about 5 hours ago and was accompanied by an intense non-productive cough that woke him up from sleep. Food seemed to make it worse but small sips of water made it better. Mr.R also has diarrhea*24 hrs which is mostly opaque water, denies dysphagia, abdominal pain, nausea or blood in stool. Pt admits to DOE (can walk half a block), edema, loss of appetite, fatigue, chills, night sweats, generalized weakness and unintentional weight loss of 2kg in the last few weeks. Denies wheezing, hemoptysis, cyanosis, orthopnea, PND, chest pain, palpitations or known heart murmur. Pt was unable to make it to his dialysis because of a generalized weakness and is currently on a CPAP. Wife states this has never happened to him before.
PMH
DM * 10 years
HTN – 25 yrs
Renal Cancer in the right kidney (Nephrectomy in 2017)
ESRD diagnosed in 2017
Immunizations up to date, last flu shot Oct 2019
PSH
Right kidney nephrectomy Oct 5 2017 (NY Presbyterian Queens Hospital), on dialysis since.
Pt receives dialysis at NY Presbyterian Queens every Monday, Wednesday and Friday.
Blood transfusion Oct 5 2017, denies complications
Medications:
Pt did not have his list of medications with him, ED was in the process of obtaining it. Wife says he was taking Insulin, K powder, a blood thinner and a Fish oil supplement.
Allergies:
NKDA
Family History:
History was obtained from his wife who has not known his family
SH:
Travel – denies
Mr.V is married, used to work as a chef until he retired due to ESRD. He lives with his wife, denies having pets. His typical food is Thai with emphasis on rice, spices, beef, chicken and seafood. Denies consuming salt. Sleeps 12-16 hrs/day. No exercise due to DOE (can walk ½ block). Denies being sexually active.
ROS:
General: Alert and oriented*3 Overweight edematous male, well groomed, on CPAP.
Vitals: BP*2, in both arms 140/90, 138/90
HR78, RR19, T38C, Osat 92, Hight5.9, Weight192, BMI 27.5
Physical Exam:
Skin: warm & moist, good turgor. Nonicteric, no lesions noted, no scars, tattoos.
Hair: average quantity and distribution.
Nails: no clubbing, capillary refill <2 seconds throughout.
Head: normocephalic, atraumatic, non tender to palpation throughout
Eyes – symmetrical OU; no evidence of strabismus, exophthalmos or ptosis; sclera white;
conjunctiva & cornea clear.
Visual acuity (uncorrected – 20/20 OS, 20/20 OD, 20/20 OU).
Visual fields full OU. PERRLA , EOMs full with no nystagmus
Fundoscopy – Red reflex intact OU. Cup:Disk < 0.5 OU/no evidence of A-V nicking, papilledema, hemorrhage, exudate, cotton wool spots, or neovascularization OU.
Nose – 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
Lips – 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; scars. Non-tender to
Palpation; continuity intact **.
Teeth – Good dentition / no obvious dental caries noted.
Gingivae – Pink; moist. No hyperplasia; masses; lesions; erythema or discharge.
Non-tender to palpation.
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
** Please note – you cannot say the palate continuity is intact unless you palpated it with a gloved finger – if you only inspected it, omit this statement. Similarly, if you didn’t palpate the lips, tongue or other structures do not report on palpation of them.
Neck – 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 palpable
adenopathy noted.
Thyroid – Non-tender; no palpable masses; no thyromegaly; no bruits noted.
Heart: 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. Regular rate and rhythm (RRR). S1 and S2 are distinct with no murmurs, S3 or S4. No splitting of S2 or friction rubs appreciated.
Chest – Symmetrical, no deformities, no evidence trauma. Respirations unlabored / no paradoxic respirations or use of accessory muscles noted. Lat to AP diameter 2:1. Non-tender to palpation.
Lungs – Clear to auscultation and percussion bilaterally. Chest expansion and diaphragmatic excursion symmetrical. Tactile fremitus intact throughout. No adventitious sounds.
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
