Date: 06/04/2022
Full name: CE
Address: New York, NY
Date of Birth: 01/21/1936
Location: Metropolitan Hospital
Religion: Catholic
Source of Information: Self
Reliability: Reliable
Source of Referral: None
Mode of Transport: Self
Chief Complaint: “First visit” to establish care
History of Presenting Illness:
84 y/o Filipino female living with her daughter and independent in all ADLs with a PMHx of Asthma, Gallstones, GERD, Osteoarthritis and Cataracts presents with her daughter to the Geriatric clinic today for her first visit here and to establish care. The patient was previously seen at the Bellevue Hospital. Her daughter states that the patient had travelled to the Philippines for vacation but had to remain there for the past 3 years due to the pandemic and the lockdown. The patient states that she uses her albuterol inhaler only as needed which often is about twice a week. She was previously on celecoxib for arthritis, which was prescribed by her doctor in the Philippines, but she currently is not using it. She did not bring any of her medications with her today. She has no other complaints currently.
Past Medical History:
– Asthma
– Gallstones (while in the Philippines and per patient was given medications only)
– GERD
– Osteoarthritis of multiple joints including her neck, shoulders, low back and knees
– Cataracts
Past Surgical History:
– Exploratory laparotomy (Patient and daughter state that it was an error for a misdiagnosis of what was eventually found out to be internal hemorrhoids)
Medications:
– Albuterol Inhaler
– Celecoxib (no longer using)
– Tylenol as needed.
– She takes multivitamins, 1 tablet a day.
Allergies:
-No known drug, food or environmental allergies.
Family History:
Mother – Deceased. Denies pmhx of CAD, DM, Cancer
Father – Deceased. Denies pmhx of CAD, DM, Cancer
Children – 1 Daughter and 2 sons. Daughter has hx of high BP and both brothers pmhx is unknown.
Social history:
– She is widowed and lives with her daughter at the daughter’s home.
– she graduated Highschool and worked as an insurance agent when she was younger,
– She can shower on her own. She is also able to cook and clean sometimes but does states that she requires help sometimes from her daughter with the chores.
– She tries to go walking every day and walks about 2 blocks on average.
– She drinks wine occasionally but only when out for dinner events with her family.
– She denies any illicit drug use
– She states that she has never smoked
– She is not sexually active.
Review of system
General – denies change in appetite, fever, or unintentional weight loss
Skin, hair, and nails – denies rash or diaphoresis
Head – denies any pain or pressure
Eyes – mentions hx of Cataracts and c/o of reduced vision
Ears – denies any difficulty hearing, denies any ear pain
Nose /Sinuses – denies current congestion
Mouth/ throat – complains of dry mouth but no dysphagia.
Neck – denies any pain
Breast – denies any pain, nipple changes
Pulmonary system –denies any cough, chest tightness, shortness of breath or wheezing. The patient is able to walk at least 2 blocks before exhaustion.
Cardiovascular system – denies any chest pain or palpitations or leg swelling
Gastrointestinal system – denies abdominal pain, diarrhea, bloody stool, constipation, nausea, or vomiting. Complains of occasional acid reflux occur about almost every day.
Genitourinary system – Denies dysuria and hematuria.
Menstrual /obstetrical – denies any abnormal bleeding. In menopause.
Nervous – denies any headache. denies dizziness.
Musculoskeletal – complains of mild arthralgias in the shoulders, knees, neck, and low back
Peripheral vascular system – denies any pain in calves or swelling in legs
Hematological – denies spontaneous bleeding
Endocrine system – Denies polydipsia
Psychiatric – Occasional feeling of loneliness but denies any depression or sleep disturbances. States she is occasionally forgetful.
Geriatric assessment:
ADLs: Fully independent in all
IADLs: Needs assistance with household chores such as cleaning and cooking sometimes. She needs assistance with transportation, paying bills and shopping.
Visual impairment: She states she was diagnosed with cataracts by her doctor in the Philippines and was referred for surgery, but she refused. She complains of poor vision bilaterally but uses reading glasses and states she sees well with her glasses.
Hearing: Good hearing w/o impairment
History of falls in the last year: None
Assistive devices: None
Gait: Her gait is good, and she does not require support.
Urinary incontinence: No complaints
Fecal incontinence: No complaints
Osteoporosis: She states she had Dexa scan in 2009 and the results were normal.
Cognitive impairment: She states that she is occasionally forgetful and may forget where she left things. She is a high school graduate and used to work as an insurance agent
Mini-Cog test: She had some delayed recall but scored 3/3 on all items and had a normal clock drawing test.
Depression: She complains that she occasionally feels lonely when her daughter and grandchildren go to work and school, but she denies depression.
Safety issues: None at home
Health Care Proxy: Her daughter is her assigned proxy
Advanced directives: Wants to be full code
Physical exam:
Vital signs:
Using machine: BP (Sitting & Left arm) 123/ 70 mmHg
Pulse: 93 bpm RRR
RR: 18 breaths/min unlabored
T: 97F using forehead
O2 sat: 97% on room air
Weight: 120lbs, Height: 4’11, BMI = 24.2 kg/m^2 (normal)
General appearance: Elderly female, is alert and oriented to person, place and time. She appears in no acute distress. Appears stated age and is dressed appropriately for weather. No tremors noted.
Skin, hair, and nails: Skin is warm to touch. No diaphoresis. No Jaundice.
Head: Atraumatic and normocephalic.
Eyes: Pupils are equal and round. Lens appear cloudy bilaterally. Sclera is white without icterus and conjunctiva is normal. Extraocular movements intact. No discharge.
Ears: External ears appear normal bilaterally and the tympanic membrane is intact in the left and right ears. Some cerumen in the ears but no impaction bilaterally. No cauliflower ears. No tenderness to palpation of the auricle.
Nose: Patent bilaterally. No trauma or rhinorrhea. No tenderness on palpation of the sinuses.
Mouth: Oral Mucosa is moist. No central cyanosis. No tonsillar swelling or exudates. Upper and lower dentures were present. No bleeding noted from the gums.
Neck: Supple, non-tender. No cervical lymphadenopathy noted. No enlarged thyroid.
Throat: Uvula is midline.
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. No murmurs or gallops.
Abdominal exam: Non distended. No masses palpated. Bowel sounds present. Abdomen is soft and non-tender. No guarding or rebound.
Genitourinary: No tenderness on palpation of the suprapubic region.
Endocrine system: No goiter noted.
Neuro exam: She is alert and oriented to person, place and time. No nystagmus or focal deficit. On mini cog she had some delayed recall but scored 3/3 on all items and had a normal clock drawing test.
Musculoskeletal: Normal active and passive ROM present in the in cervical region, and in upper and lower extremities bilaterally.
Peripheral vascular system: Varicose veins were present bilaterally but no pedal edema or swelling bilaterally in both lower extremities. Right and Left Feet exam shows some varicose veins but normal skin integrity, no ulcers or blister or callus but skin is dry. Dorsalis pedis pulse was present bilaterally.
Psychiatric: Normal mood, affect and behavior. She complains that she occasionally feels lonely when her daughter and grandchildren go to work and school, but she denies depression.
Assessment:
84 y/o Filipino female with a PMHx of Asthma presents with her daughter to the Geriatric clinic today for her first visit here and to establish care. She has a hx of Cataracts and poor vision which is her main complaint today. The lens was mildly cloudy on exam.
Problem list:
- Degenerative joint disease
- Asthma
- GERD
- Age related Cataracts bilaterally
- Healthcare maintenance
- Osteoporosis screening
Plan:
- Degenerative Joint disease of multiple joints: Patient was able to have full ROM on PE. Will prescribe topical pain reliever (Menthol) and acetaminophen as needed. Will advise to continue to maintain physical activity as can be tolerated.
- Asthma: She is well controlled on her albuterol inhaler (typically uses twice a week). Since she was in the Philippines for the past 3 years will refer to Pulmonology and have repeated PFTs.
- GERD: will obtain a stool test for H. Pylori Ag. Will also start on a trial of Famotidine
- Age related Cataracts: Will refer to Ophthalmology
- Osteoporosis screen: Will schedule another Dexa scan as the patients last Dexa Scan was in 2009.
- Healthcare maintenance
– Advanced directives were set up and healthcare proxy was confirmed.
– Patient was encouraged to have Shingrix vaccine (only pending vaccine) which she refused.
– Up to date on Tdap, pneumococcus, and Covid-19 booster vaccines.
-Should return to clinic in 1 month and to review her results.
Labs later obtained and reviewed: CBC with differential (mildly elevated WBC – 11.41, all else is normal), BMP (normal), Liver Function tests (Normal), Lipid panel (High cholesterol – 223, LDL is 158, and HDL is less than 43), renal panel (normal), thyroid panel (normal) and Urinalysis (normal but slightly cloudy urine.), Low vitamin D 25 hydroxy: 28.2 and Hemoglobin A1c was 6.1.
