MEDICAL HISTORY                     Date:        04/17/21                   Time: 11:00

IDENTIFICATION:         S.W.                            

Sex:          M           Race:    African American           

Nationality:    US        Age: 45   Marital status: Married

Address:        N/A                               Religion: N/A

PCD: O.Dairo

Informant : self            Reliability:          reliable                    Referral:  none

HPI

C/C: Cough, shortness of breath, bilateral lower extremity edema

45 y/o M w a PMH of Asthma, HTN and ESRD s/p kidney transplant walked in today with a c/o cough and ankle swelling x 2 days. The cough is sometimes productive, bringing up white frothy sputum. Patient states the cough is worse when he is laying down and that he needs 2-3 pillows to sleep comfortably. He is also short of breath, even at rest. Patient states he is complaint with all his medications, however, his blood pressure is still not controlled. Patent seems in a rush, requesting antibiotics for his cough so he can return to work. Denies any chest pain, syncope, fever, chills, headache or dizziness.

PMH:

• HTN
• Asthma
• ESRD

PSH:

• Lt Arm surgery – graft for dialysis
• Kidney transplant 04/2018
• Graft removal 11/20/2019
• No known vaccination status

Family Hx:

• Father: deceased at 56, cause unknown
• Mother: deceased at 65, Heart failure
• Siblings: alive & well

Social Hx:

• Denies drinking, alcohol, caffeine or illicit drug use
• Lives with his wife, no pets

Medications:

• Prednisolone tab 5 mg 1/day
• Albuterol Sulfate HFA 108 (90 base) 1 puff as needed  inhalation every 4 hrs
• Nifedipine ER 90 mg 1/day
• Atorvastatin Calcium tab 40mg
• Bumetanide 1 mg tab 1/day
• Carvedilol 25mg tab twice a day
• Entresto 97-103mg tab 1/day
• Spironolactone 25mg tab 1/day
• EPO IM injection 1/month

Allergies: NKDA NKEA NKFA

Review of  Systems:

General: Denies any Fever, chills, night sweats, fatigue, weakness, loss of appetite, recent weight gain or loss

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

Head: Headache, vertigo, head trauma, unconsciousness, coma, fracture

Eyes: Denies visual disturbances, fatigue, lacrimation, photophobia, pruritus

 Ears: Denies deafness, pain, discharge, tinnitus, or use of hearing aids

Nose/Sinuses: Denies discharge, epistaxis, obstruction

 Mouth and throat: Denies any bleeding gums, sore tongue, sore throat, mouth ulcers, voice changes, or use of dentures

Neck: Denies any localized swelling/lumps, stiffness/decreased range of motion

Pulmonary system: Admits to dyspnea, SOB, cough, orthopnea, PND; Denies any wheezing, hemoptysis, cyanosis

Cardiovascular system: Admits to HTN, edema/swelling of ankles or feet; Denies chest pain, palpitations, irregular heartbeat, syncope, known heart murmur

Gastrointestinal system: Denies any changes in appetite, intolerance to foods, nausea and vomiting, dysphagia, pyrosis, flatulence, eructation, abdominal pain, diarrhea, jaundice, change in bowel habits, hemorrhoids, constipation, rectal bleeding, blood in stool or flank pain

Genitourinary: Admits to occasional nocturia; denies urinary frequency, incontinence, dysuria, urgency, oliguria, polyuria

Sexual history: Sexually active with his wife only; uses condoms

Musculoskeletal system: Denies any muscle/joint pain, deformity or swelling, redness, arthritis

Peripheral Vascular system: Denies any intermittent claudication, coldness of trophic changes, varicose veins, peripheral edema, color change

Hematologic System: denies anemia (takes EPO injections monthly), easy bruising or bleeding, lymph node enlargement, history of DVT/PE

Endocrine system: Denies polyuria, polydipsia, polyphagia, heat or cold intolerance, goiter, hirsutism

Nervous system: Denies seizures, loss consciousness, sensory disturbances (numbness, paresthesia, dysesthesias, hyperesthesia), ataxia, loss of strength, change in cognition/mental status/memory, weakness (asymmetric)

Psychiatric: Denies depression/sadness(Feelings of helpless, feelings of hopelessness, lack of interest in usual activities, suicidal ideation), anxiety, obsessive/compulsive disorder

DDX:

• Pulmonary edema due to heart failure or ESRD – most likely due to PMH
• Asthma exacerbation – possible but not likely
• Bronchitis – possible but not likely
• Pneumonia – possible but not likely

Physical Exam:

Vital Signs

BP: 175/147 ; RA; supine

Pulse: 103 BPM                O2SAT: 95 % RA; 

Respirations: 18/min, somewhat labored but no retractions; Temperature: 97.5F oral

Height: 5.9.     Weight: 146lbs.    BMI: 21.25

General:Alert & oriented, short of breath

Skin: warm & moist, good turgor. Nonicteric, no lesions noted, no scars, tattoos

Head: normocephalic, atraumatic, non tender to palpation throughout

Eyes: PERRLA; symmetrical OU; no evidence of strabismus, exophthalmos or ptosis; sclera white; conjunctiva & cornea clear.  

Ears: Symmetrical and normal 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 normal position AU.

Nose and sinuses: Symmetrical / no masses / lesions / deformities / trauma / discharge. Septum midline

Throat: do gross deformities noted in mouth, dentition and oropharynx. Throat non-injected, no exudates, uvula midline.

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.

Chest – Symmetrical, no deformities, no evidence trauma.   Respirations are mildly labored – patient is short of breath at rest; no paradoxic respirations or use of accessory muscles noted.  Lat to AP diameter 2:1.   Non-tender to palpation.

Lungs: Mild labored breathing; decreased air entry at lung bases; dullness to percussion; Chest expansion and diaphragmatic excursion symmetrical.

Heart: JVP is 3.5 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. Systolic murmur noted. No splitting of S2 or friction rubs appreciated.

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. No hepatosplenomegaly to palpation

Peripheral Vascular: The extremities are normal in color, size and temperature. Pulses are 2+ bilaterally in upper and lower extremities. No bruits noted. No clubbing, No stasis changes or ulcerations noted. 4+ pitting edema in both extremities.

MSK: No deformity, no edema, no tenderness, FROM

Neuro: Alert. Normal speech, normal tone, normal gait. CN II – XII intact. Muscle strength 5/5 throughout. Sensation intact. Negative Romberg. Negative Pronator drift. Normal finger-nose-finger. No nystagmus.

DDX:

• Pulmonary edema due to heart failure or ESRD – most likely due to PMH and PE findings (crackles at lung bases, 4+ pitting edema, foamy sputum)
• Asthma exacerbation – not likely due to no wheezing, no cough
• Bronchitis – not likely
• Pneumonia – not likely

Assessment:

• Fluid overload
• Systolic congestive heart failure
• Essential Hypertension
• Mild intermittent Asthma

Plan:

1. Pulmonary edema/fluid overload: Refer to Emergency Room

2. Heart failure: In view of edema, acute decompensation of heart failure, refer to ED. 911 called

3. HTN: Discuss compliance with HTN medications, exercise as tolerated and dietary modifications

4. Asthma: stable at this time

5. Follow up appointment within 1 week from discharge from the hospital