MEDICAL HISTORY Date: 04/17/21 Time: 11:00
Sex: M Race: African American
Nationality: US Age: 45 Marital status: Married
Address: N/A Religion: N/A
Informant : self Reliability: reliable Referral: none
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.
- Lt Arm surgery – graft for dialysis
- Kidney transplant 04/2018
- Graft removal 11/20/2019
- No known vaccination status
- Father: deceased at 56, cause unknown
- Mother: deceased at 65, Heart failure
- Siblings: alive & well
- Denies drinking, alcohol, caffeine or illicit drug use
- Lives with his wife, no pets
- 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
- 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
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.
- 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
- Fluid overload
- Systolic congestive heart failure
- Essential Hypertension
- Mild intermittent Asthma
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