H&P 2 (Internal Medicine)

Date: 02/24/2022

Full name: R.L

Address: Flushing, NY

Date of Birth: 02/01/1928

Location: New York Presbyterian Queens Hospital 

Religion: None

Source of Information: Daughter 

Reliability: Reliable 

Source of Referral: PCP

Mode of Transport: Daughter 

Chief Complaint: “Swelling in both legs” x 6 days and “hyponatremia”

History of Presenting Illness:

94 y/o female with PMHx of dementia, anxiety, and left knee pain replacement was sent by PCP to the ED for evaluation of hyponatremia. The patient has dementia and could not provide a full history, so it was obtained from her daughter. Per the daughter the patient has had swelling in both legs which was also “oozing out fluids” for 6 days. The PCP started the patient on Lasix 20 mg daily for x 5 days. Follow up labs were obtained by the PCP 2 days ago which showed that the patient’s sodium levels were low (126). Sodium in the ED was 125, Troponin 0.028, Pro-BNP 2300. US of lower extremities show no evidence of DVT. 

Past Medical History:

– Dementia

– Anxiety

– Left Femoral fracture x 5 years 

– Questionable thyroid disease.

Past Surgical History:

– Left knee replacement x 5 years  


– Acetaminophen (Tylenol) tablets 325 mg  

– Quetiapine 25mg once at night 

– Furosemide 20 mg once a day

– Xanax (alprazolam) 0.5 mg 3 times a day 

– Lamotrigine 25 mg once a day  

– Mirtazapine 15 mg at before bed 


-No known drug, food or environmental allergies.

Family History:

Mother – 90 years, deceased. No significant hx reported 

Father –93 years old, deceased. No significant hx reported

Daughter – 63 years old with diabetes mellitus type 2. 

Social history: 

– Widowed and lives alone  

– Has 24 hr home health aide but daughter comes by bi-weekly to check on her 

– Denies alcohol use 

– Denies drug use 

– Has never smoked 

Review of system

General – Denies fever and chills

Skin, hair, and nails – complains of fluid oozing out from both lower extremities. Denies rash 

Head – Denies any headache

Eyes – denies pain or change in vision 

Ears – denies any new changes to hearing 

Nose /Sinuses – denies epistaxis 

Mouth/ throat – denies any pain or swelling

Neck – denies any pain or swelling

Breast – denies any pain, nipple changes

Pulmonary system – denies any cough, shortness of breath or wheezing

Cardiovascular system – denies any chest pain or palpitations

Gastrointestinal system – denies abdominal pain, diarrhea, constipation

Genitourinary system – denies dysuria and hematuria 

Menstrual /obstetrical – denies any abnormal bleeding

Nervous – denies dizziness  

Musculoskeletal –swelling in both legs 

Peripheral vascular system – Denies any pain in calves

Hematological – denies spontaneous bleeding

Endocrine system – denies polydipsia 

Psychiatric – complains of anxiety.  

Physical exam:

Vital signs: 

Using machine: BP (left arm) 92/ 61 mmHg

Pulse: 88 bpm RRR

RR: 16 breaths/min unlabored

T: 36.7C using finger 

O2 sat: 93% on room air 

BMI: Weight: 116lbs, Height: 5’2 = 21.2 

General appearance: Elderly white female, is alert but to person but is not oriented to place and time. She appears in no acute distress. She is dressed appropriately and has a normal affect. She is friendly and cooperative. No tremors noted. 

Skin, hair, and nails: Skin is warm to touch. Hair on scalp is thin. She has a bluish discoloration over her left hand which appears to be a bruise. No diaphoresis. No spoon nails, or splinter hemorrhage. No jaundice. Sacral ulcer seen with an old abrasion on the lateral left leg. Erythema noted on the anterior right lower extremity. Bruising also noted on anterior right foot.

Head: Atraumatic and normocephalic. No moon facies.

Eyes: PERRLA. Sclera is white without icterus. Extraocular movements intact. No nystagmus. Conjunctiva is pink. 

Ears: No cauliflower ears. No pre-auricular sinus. No tenderness to palpation of the auricle. 

Nose: Patent bilaterally. No bleeding noted externally or epistaxis. No trauma to nose. 

Mouth: Oral Mucosa is moist, but lips are chapped and dry. No central cyanosis. No erythema or bleeding. Many cavities noted on teeth with some missing teeth. 

Neck: Supple, non-tender. No lymphadenopathy noted.

Throat: Uvula is midline. The soft palate rises with swallowing. 

Pulmonary: Lungs clear to auscultation bilaterally. Pulmonary effort is normal. No wheezing or rales.

Cardiovascular: Normal S1 and S2 sounds with a regular rate and rhythm. 

Abdominal exam: Non distended. Bowel sounds present in four quadrants. Abdomen is soft and non-tender. No guarding or rebound. 

Breast: No dimpling noted. Nipples and breast are symmetric.   

Genitourinary: wearing an adult diaper but has long brown pubic hair. 

Menstrual and Obstetrical: No menstruation or abnormal bleeding noted on diaper.

Endocrine system: No diaphoresis. No goiter. 

Neuro exam: No nystagmus or focal deficit. She is alert but oriented to self. She seems to confuse the nurse as being her mother. May be her baseline due to history of dementia.

Musculoskeletal: Active and passive ROM present in the in all extremities with no tenderness note. 

Peripheral vascular system: +2 pitting edema bilaterally in both lower extremities but greater in right leg than leg. Negative Homans sign. Capillary refill less than 2 seconds.


94 y/o female with PMHx of dementia, anxiety, and left knee pain replacement was sent by PCP to the ED for evaluation of hyponatremia. In the ED labs were significant for sodium of 125 and Troponin of 0.028, Pro-BNP of 2300. CXR showed increased interstitial markings bilaterally. Lower extremity US shows no evidence of DVT.


  1. Pulmonary edema: CXR showed increased interstitial markings bilaterally and Pro-BNP of 2300.
  2. New Onset Congestive heart failure: Edema in legs and elevated pro-BMP.
  3. Hyponatremia: Sodium in the ED was 125. 
  4. DVT: Swelling in lower extremity and history of knee replacement.

Problem list:

  1. Pulmonary Edema 
  2. CHF
  3. Hyponatremia
  4. Anxiety: ongoing previous medical problem 
  5. Dementia: on going previous medical problem


1. Pulmonary edema: Give Lasix 40 mg x 1 dose IV and f/u w/ renal and cardiology 

2. Congestive Heart failure: Lasix as stated above. Fluid restriction. Will get a TTE to assess EF and any structural abnormalities. F/u with cardiology. 

3. Hyponatremia: Fluid restriction as stated above for now and f/u with Nephrology. 

4. Anxiety: Continue at home Xanax 

5. Dementia: Continue at home Quetiapine. 

Follow- up findings:

  1. TSH: was 0.67 which is normal which may r/o thyroid disease.
  2. Sodium was brought by up to 135 before discharge
  3. Following treatment with 40 mg IV Lasix the Edema had improved. Pt was sent home to continue on 20 mg PO Lasix and f/u with PCP.
  4. TTE showed LV EF of 65-70% with mild aortic regurg. Left atrium was enlarged but LV function was normal.