Date: 05/11/2021
Hospital Visit (Internal Medicine)
Identifying data:
Full name: Ms. CR
Address: Glendale, NY
Date of Birth: 05/30/1944
Location: New York-Presbyterian, Flushing, NY
Religion: non-religious
Source of Information: Self
Reliability: Reliable
Source of Referral: Primary Care Provider
Mode of Transport: Ambulance
Chief Complaint: “I was not talking properly” x 1 day ago.
History of Presenting Illness:
Patient is a 76-year-old female with PMHx of hypertension and sleep apnea who presented to the ED yesterday with complaints of changes to her speech which lasted for about 15 minutes. She states that yesterday afternoon she was at home and talking on the phone with a friend when all of a sudden, her friend noticed that the patient was not speaking properly and would say odd things and could not finish her sentences. The patient states that she felt some confusion at the time but was aware that her speech was off and not sensible. She states that her friend then called a nurse, and eventually the patient’s PCP who advised that the patient go to the hospital. The patient states that she was reluctant to go at first, but her daughter called an ambulance and also encouraged her to go to the ED. The patient denied any facial or general weakness, visual changes, pain, headache, tingling sensations peripherally or around her face, denied any SOB, dyspnea, nausea, or syncope. She states that while at home, she was advised by another family member to “chew” 3 baby aspirins immediately following the episode. She also states that 2 weeks before this episode her blood pressure had been much more elevated than usual to around 185mmhg – 193 mmHg and she was not sure why but states that 10 days ago, her PCP increased the dosage for her antihypertensive medications and added amlodipine and losartan to her regimen which she states helped lower her blood pressure. The patient denies any further complaints.
Past Medical History:
Hypertension, controlled on medication
Vertigo for several years (could not estimate how long)
Sleep apnea x 40 years
Past Surgical History:
-Laryngotomy to stop snoring
-Inspire implant for sleep apnea
-Hysterectomy x 57 years
-Rotator cuff repair
-Eye surgery for cataracts x 1 year
-Denies any appendectomy or tonsillectomy
Medications:
Metoprolol: increased from 50 mg to 100mg (10 days ago)
Recent additions (10 days ago)
-Amlodipine 5mg
-Losartan 100mg
-Takes “charcoal pills” during episodes of diarrhea
Allergies:
Anesthesia- nausea and vomiting
NKDA
Denies food and environmental allergies
Family History:
Mother – had heart problems (could not specify what problem), had open heart surgery at 80 years old. Deceased at 90 from natural causes.
Father – History of diabetes. Deceased at 63 years old due to a heart attack.
Daughter – Liver Cirrhosis at 57 years old.
Social history:
-She is a married female with a daughter, but the patient has been married four times.
-Denies alcohol use
-Smoked cigarettes x 29 years.
Diet – States she eats a regular diet, but it is not a very healthy one.
Work- States she worked at this hospital for 15 years in admissions before she retired.
Review of system:
General – denies generalized weakness/fatigue, chills, or fever
Skin, hair, and nails- denies diaphoresis
Head – Denies headache, has a history of vertigo
Eyes – history of surgically corrected glaucoma. Denies any visual changes. She does not wear glasses.
Ears – denies deafness
Nose /Sinuses – states she sometimes has a runny nose when outdoors.
Mouth/ throat – denies tonsillectomy
Neck- denies any pain
Breast –
Pulmonary system- Denies dyspnea, cough, shortness of breath. Complains of sleep apnea and uses “inspire” an implanted device
Cardiovascular system- denies chest pain or syncope. Has a history of hypertension.
Gastrointestinal system – denies nausea, vomiting, diarrhea, constipation, but states that she is lactose intolerant.
Genitourinary system – states she has urinary frequency at night (nocturia) but denies any dysuria or discharge.
Menstrual /obstetrical – G1P1 (NSVD x1). Currently in menopause and has a history of a hysterectomy.
Nervous -Denies headache, loss of consciousness, facial and general weakness. Has a history of vertigo.
Musculoskeletal- denies any muscle/ joint pain.
Peripheral vascular system –
Hematological –
Endocrine system – complains of nocturia
Psychiatric –
Physical exam:
Vital signs:
L (supine): 132/88mmHg
Pulse: 68 bpm, regular
RR: 15/min unlabored
T: 36.7 Celsius
O2 sat: 98% on room air
BMI: 26.6 kg/m2 (weight: 133lbs, Height: 4’11)
General: Caucasian, overweight female, alert and oriented to person, place, and time (x3), neatly groomed, appears as stated age, appears in no acute distress.
Skin, hair, and nails: Skin appears to be of even skin tone, poor skin turgor, hair is evenly distributed across arms and upper body, no unusual discoloration or bruising noted along arms and face. No Jaundice noted.
Head: Wrinkles across forehead and face. No moon facies, acromegaly, hirsutism, noted. No masses or lesions noted on the face. No tenderness to palpation of the head. Grey thin hair on scalp but appears evenly distributed. No seborrhea, lice, or mites. No bruising, bumps, or lacerations noted.
Eyes: No periorbital swelling, no strabismus. No lacrimation or unusual discharge noted.
Ears: No periauricular sinus, no dermatitis noted, no tenderness to palpation of the auricle. No mastoiditis or swelling and erythema noted around the auricle.
Nose: Patent bilaterally. No external lesions or masses noted. No bleeding seen on inspection and no tenderness to palpation around the maxillary and frontal sinuses.
Neck: On inspection no sign of goiter.
Mouth: no central cyanosis around the lips. No swelling of upper or lower lips noted.
Pulmonary: Clear to auscultation Bilaterally. No wheezing, rales, rhonchi, or stridor noted.
Cardiovascular: Normal S1 and S2 sounds. No JVD noted. No thrills and heaves noted.
Abdominal exam: present bowel sounds in all four quadrants, no abdominal hernia or distension noted. Tympany was noted in all four quadrants. No pain with light palpation and no fluid wave noted.
