H&P 1

Identifying Data 

Name: SS

Sex: Female

Age: 69

Date and time: 5/4/2021 8:00AM 

Location: Queens Hospital Center, Med/Surg Unit

Source of information: self, reliable 

Chief complaint: lower back pain X 3 days 

HPI: 69-year-old woman with PMH of HTN, DM2, HLD, hypothyroidism (s/p thyroidectomy for enlarged thyroid gland from Jamaica (country) presented to the ER yesterday 5/3/21 with complaint of lower back pain for the past three days. She has been having this lower back pain intermittently for the past 2 years after a fall in her home country. She stated she tripped and fell, lost her balance and hit her back. She was never evaluated for this injury. The intermittent pain has been managed previously with tylenol as needed. She came to the US from Jamaica two weeks ago. She stated the current bout of back pain began Saturday 4/1/21 after she lifted something heavy. The pain is the same as in previous episodes. The pain is located across the lower back, 5/10 intensity, dull, nonradiating, worse with movement particularly from side to side. She took tylenol at home with some relief. In the ED she was treated with tylenol 650 mg Q4H as needed and Aspirin 325 mg. BMP, CBC with differential, Troponin, 12-lead ECG, CXR, and thoracic spine XR were ordered. Troponin level was found to be elevated and the patient was admitted for elevated troponin to rule out NSTEMI. 

Currently the patient stated her back pain has resolved with tylenol 650 mg. She denies any symptoms at this time. She denies chest pain, shortness of breath, palpitations, diaphoresis, nausea, vomiting, leg swelling, orthopnea, PND, urinary retention, urinary incontinence, decreased sensation, numbness. Patient can walk several blocks, and up 1-2 flights of stairs. She denied a history of cardiac disease. 

Past medical history: 

HTN X10 years

DM2X10 years

HLDX10 years

Hypothyroidism s/p thyroidectomy X5 years 

Hospitalizations: 

Denied previous hospitalizations other than for surgery (see below) 

Immunizations: 

Patient is up to date on immunizations. 

Past surgical history: 

ThyroidectomyX5 years ago for enlarged thyroid, Jamaica. No complications reported. 

Hysterectomy in 2015, in Jamaica, no complications reported. 

Appendectomy remote, patient denies remembering anything about the procedure

Medications: 

Galvus/Met 40/1000 mg daily for DM2 

Diamicron 30mg daily for DM2

Synthroid 250 mcg daily for hypothyroidism

Enalapril 20 mg daily for HTN

Amlodipine 10 mg daily for HTN

Atorvostatin 10 mg daily for HLD

Allergies: patient denied allergies to medication, food and environment

Family history: 

Maternal grandfather: deceased from MI unknown age

Mother: DM2, HTN deceased at 84

Father: HTN decreased at 87 

Denied knowledge of other grandparents’ medical history. Denied family history of thyroid disease, kidney disease, allergies, lung disease, GI disease, urinary tract disease, psychiatric disorders, nervous disorders.

Social history: patient denies smoking, drinking and use of recreational drugs. Patient denies sexual activity. Patient came from Jamaica 2 weeks ago. She will remain here in the US until July with her daughter. For breakfast she eats eggs or pancakes, for lunch sandwiches with deli meat and a slice of cake, for dinner takeout with a variety of proteins and vegetables. Patient does not exercise. Patient denies difficulty with sleeping.  

Review of systems: 

General: patient denied nausea, anorexia, general weakness, fever, chills, vomiting, fatigue, diaphoresis, night sweats and changes in weight

Head: patient denied trauma , headache, confusion, lightheadedness, changes in vision, loss of consciousness 

Neurologic: patient denied slurred speech, neck stiffness, decreased sensation, numbness, tingling, syncope 

Eyes: denied blurred vision, itching, photophobia, discharge, swelling. Does not wear corrective lenses

ENT: patient denied vertigo, rhinorrhea, stuffiness, sneezing, sore throat, swollen lymph nodes, tinnitus, neck pain

Cardiac: patient denied leg edema, claudication, known heart murmurs, chest pain, shortness of breath, palpitations 

Pulmonary: patient denied cough, shortness of breath, pain with inspiration, wheezing, hemoptysis 

Hematology: patient denied bruising, anemia 

Skin: patient denied rash, sores, itching 

GI: patient denied bowel changes, abdominal pain, diarrhea, constipation, dysphagia

GU: patient denied urgency, dysuria, polyuria, hematuria, nocturia, incontinence. Patient is postmenopausal at 53, denies dysparenuia, dryness, itching. Patient is G2P2 both NSVD.

MSK: patient denied joint pain and swelling 

Psychiatric: patient denied anxiety, depression, mood changes.

Physical exam: 

Vitals: 99.0 F orally, HR 86 regular, BP 136/86 right arm sitting, height 5’3” weight 196 lb BMI 34.7 RR 16 unlabored, O2 97% on room air

General: 69 female, alert and oriented X3, obese, appears stated age. 

Head: normocephalic and atraumatic

Eyes: no eyelid swelling, lesions noted externally. PERLLA, non icteric, no conjunctival injection. Visual fields full by confrontation bilaterally. EOMIs. 

ENT: mucus membranes moist, no erythema or exudate in the back of the throat, no lymphadenopathy. Trachea midline, thyroid not-enlarged. Uvula midline. 

Cardiac: regular rate and rhythm, S1 and S2 auscultated. no murmurs, rubs or gallops. Radial pulses 2+ bilaterally, capillary refill < 2 seconds bilaterally. No leg edema. 

Pulmonary: lungs clear to auscultation bilaterally, no wheezes, rales or rhonchi, tachypnea. Normal respiratory effort no retractions. 

Abdominal: bowel sounds present in all four quadrants, abdomen soft and non tender, with no distention, no hepatosplenomegaly. 

Skin: no rashes, bruises or scars. No pallor noted. 

Extremity: mild tenderness to palpation of lower back paraspinally. full range of motion, strength grossly intact in upper and lower extremity. No unilateral calf swelling or tenderness. No clubbing, cyanosis or edema. DP pulses 2+ bilaterally. 

Differential diagnosis: 

1. NSTEMI 
2. Rhabdomyolysis
3. ESRD 
4. Heart failure 

Labs and imaging:   

1. BMP: Na 139 mmol/L, K 4.5 mmol/L, Cl 105 mmol/L, CO2 24  mmol/L, BUN 9 mg/dL, Cr 0.63 mg/dL, glucose 204 mg/dL, Ca 9.2 mg/dL, anion gap 10 mEq/L, eGFR >60 ml/min/1.73m2
2. CBC with differential: WBC 5.59×10^3, RBC 4.73X10^6, Hgb 12 g/dL, HCT 39.2%, MCV 82.9 fL, MCH 25.4 (L) pg, MCHC 30.6 g/dL, MPV 10.4 fL, RDW 14.5%, Platelets 213X10^3,
   1.  %: neutrophil 61.1, lymphocyte 29, monocyte 6.8, eosinophil 2.7, basophil 0.2, imm gran 0.2%. 
3. Troponin: 0.027 ng/mL (NL <0.010)
4. 12 lead ECG: Normal sinus rhythm at a rate of 84 
5. POC glucose: 215 mg/dL 
6. Thoracic spine XR: normal thoracic spine
7. CXR: normal chest XR 

 Assessment: 

SS is a 69-year-old female with PMH of HTN, HLD, DM2, hypothyroidism, and MSK pain admitted to medicine for elevated troponin to rule out NSTEMI. Patient has no symptoms. 

Plan: 

1. Elevated troponin: trend troponin and ECG, check CK level to r/o rhabdomyolysis. If CK is normal consider nuclear stress testing. Start ASA 81 mg tomorrow. Get an Echo to r/o heart failure. Check LFT, lipid profile. Place patient on cardiac monitoring. 
2. Back pain: Tylenol 650 mg Q4H, PRN for pain
3. DM2: monitor blood sugars before meals and at bedtime. Manage with Levemir 10 units nightly, HumaLOG 0-6 units Q4H sliding scale. 
4. HTN: continue with home meds amlodipine 10 mg daily, lisinopril 20 mg daily. 
5. HLD: continue with home meds atorvastatin 10 mg nightly 
6. Hypothyroid: check TSH, hold levothyroxine pending workup. 
7. DVT prophylaxis: SQ lovenox 40mg daily
8. Obesity: discuss with case manager for education.  

Identifying data: 

Name: N.M. 

Address: Queens, NY

Age: 69

Sex: Female

Date and time: 5/4/21 8:00AM 

Location: Queens Hospital Center, Jamaica, NY

Religion: Muslim

Marital status: widowed 

Source of information: self and medical records

Reliability: reliable

Chief complaint: “ Abdominal pain” 2 days ago

History of present illness: 69-year-old female who lives at home with her son, is ambulatory without assistance, independent in ADLs and most IADLs (see below) with PMH of ESRD on dialysis (left upper extremity fistula), type 2 DM, hypertension, right sided breast cancer s/p lumpectomy, HCV cirrhosis s/p liver transplant presented to the ED two days (5/2/21) with complaint of abdominal pain. Abdominal pain was located in the entire upper abdomen, 10/10 constant, sharp and nonradiating. Pain resolved with tylenol at home but recurred so she came to the ED. She had associated nausea but no vomiting. She had covid-19 pneumonia in February 2021 and has shortness of breath at baseline and has been on 2L of oxygen at home. No change with activity or lying flat. She denied fever, chills, chest pain, palpitations, vomiting, diarrhea, rash, broken skin, cough, phlegm, leg swelling, changes in her status of SOB. 

The patient was admitted to the step down unit on 4/2for an acute abdomen workup. The abdominal pain resolved overnight and abdominal XR confirmed no SBO or free air in the peritoneal cavity.

On physical exam the abdomen was nontender to palpation. Dialysis and home medications were resumed. Patient became tachypneic (30-35) and exhibited increased work of breathing overnight, she responded well to HFNC. She never became hypoxic on pulse oximetry. CT abdomen pelvis showed bilateral pulmonary consolidations suspicious for pneumonia. No acute abdominal pathology. CT angiogram showed no PE, but showed peripheral consolidations in the lower lobes. CXR showed pulmonary vascular congestion, bilateral consolidations in the lower lobes. An ECG was performed and showed sinus rhythm at 92, no TWI or acute ST change At this point she was treated for presumed pneumonia due to exacerbation of SOB, dyspnea, tachypnea, leukocytosis, imaging findings, and elevated procalcitonin. She was treated and responded well to meropenem, azithromycin and vancomycin. 

Currently she is hemodynamically stable and being transferred to the red team for further treatment. At the present she denies any symptoms including increased SOB, chest pain, palpitations, cough, phlegm, leg swelling, abdominal pain, nausea, vomiting, fever, and chills. She states she feels like her normal self and wants to be discharged. 

Past medical history: 

Breast cancer X February 2021 

ESRD X 2019

HTN X 10 years

DM X 10 years

Cirrhosis of the liver due to hepatitis C (2013)

Past surgical history: 

AV fistula placement in 2019, QHC no complications for ESRD requiring dialysis 

Right lumpectomy in February 2021 for right breast cancer (unspecified histology)

Liver transplantation in 2013 for HCV cirrhosis 

Medications: 

Insulin detemir 100 Unit/ML injection daily for DM2

Nifedipine 30 mg tablet, daily for HTN

Sevelamer carbonate 800 mg daily for ESRD

Tacrolimus 1 mg orally every 12 hours for immunosuppression in liver transplant

Vitamin C 1000 mg tablet, daily 

Cholecalciferol 1000 unit tablet, daily 

Multivitamin tablet, daily 

Patient is compliant with at home medications. 

Allergies: patient denies allergies to medication, food or environment 

Family history: 

Grandparents: unknown 

Parents: deceased, unknown history 

Siblings: alive, unknown history

Son: alive and well 

Denied family history of cardiac disease, metabolic disorders, cancer, thyroid disease, kidney disease, allergies, lung disease, GI disease, urinary tract disease, psychiatric disorders, nervous disorders.

Social history: 

Marital status: widowed, lives at home with her son. 

Occupation: never worked 

Habits: patient denied smoking, use of recreational drugs, drinking alcohol 

Travel: denied recent travel 

Diet: breakfast fruit/coffee, lunch sandwich (tuna/egg salad), dinner salad or protein. 

Exercise: does not exercise

Sleep: sleeps between 7-10 hours a night.

Sexual history: not sexually active

ADLs: independent 

IADLs: son handles transportation, medication and shopping. Patient is capable of preparing food, housekeeping, finances, and telephone use. 

DNR/DNI: full code 

Review of systems: 

General: patient denied nausea, anorexia, general weakness, fever, chills, vomiting, fatigue, diaphoresis, night sweats and changes in weight

Head: patient denied trauma , headache, confusion, lightheadedness, changes in vision, loss of consciousness

Neurologic: patient denied slurred speech, neck stiffness, decreased sensation, numbness, tingling, syncope 

Eyes: denied blurred vision, itching, photophobia, discharge, swelling. Does not wear corrective lenses

ENT: patient denied vertigo, rhinorrhea, stuffiness, sneezing, sore throat, swollen lymph nodes, tinnitus, neck pain, ear pain, deafness, use of hearing aids

Cardiac: patient denied leg edema, claudication, known heart murmurs, chest pain, shortness of breath, palpitations 

Pulmonary: patient denied cough, shortness of breath, pain with inspiration, wheezing, hemoptysis 

Hematology: patient denied bruising, anemia, enlarged lymph nodes, history of DVT/PE

Skin: patient denied rash, sores, itching 

GI: patient denied bowel changes, abdominal pain, diarrhea, constipation, dysphagia

GU: patient denied urgency, dysuria, polyuria, hematuria, nocturia, incontinence. Patient is postmenopausal at 54, denies dysparenuia, dryness, itching. Patient is G1P1 NSVD.

MSK: patient denied joint pain and swelling 

Endocrine: denies polyuria, polydipsia, polyphagia, heat or cold intolerance, excessive sweating, goiter or hirsutism. 

Psychiatric: patient denied anxiety, depression, mood changes.

Physical exam: 

ED vitals: temperature: 98.1 F, pulse oximetry 100% on 2 L NC, HR 92 regular, BP 132/61 mmHg RR 19 unlabored

Vitals 5/4/21: temperature 97.4 F, pulse oximetry 100% on 2L NC, HR 95 regular, BP 127/60 mmHg, RR 25 unlabored. Height 5’3”, weight 132lb, BMI 23.4 

General: General: 69 female, alert and oriented X3, thin, appears stated age

Head: normocephalic and atraumatic, non tender to palpation

Eyes:symmetric OU,  no eyelid swelling or ptosis, lesions noted externally. PERLL, non icteric, no conjunctival injection. Visual fields full by confrontation bilaterally. EOMIs. 

ENT: mucus membranes moist, no erythema or exudate in the back of the throat, no lymphadenopathy. Trachea midline, thyroid not-enlarged. Uvula midline. Dentition intact, no obvious caries. 

Cardiac: regular rate and rhythm, S1 and S2 auscultated. no murmurs, rubs or gallops. Radial pulses 2+ bilaterally, capillary refill < 2 seconds bilaterally. No leg edema. 

Pulmonary: bilateral fine crackles to auscultation. Tachypneic to 25. Normal respiratory effort, no retractions. Symmetrical chest expansion, no wheezing or rhonchi. 

Breast: scar on right breast UOQ. No lumps or dimpling. No axillary nodes palpable. No nipple discharge. 

Abdominal: bowel sounds present in all four quadrants, abdomen soft and non tender, with no distention, no hepatosplenomegaly. No guarding or rebound noted. No abdominal pulsations or bruits. 

Skin: no rashes, bruises or scars. No pallor noted. Warm and moist, non icteric skin. Normal skin turgor.

Extremity: full range of motion, strength grossly intact in upper and lower extremity. No unilateral calf swelling or tenderness. No clubbing, cyanosis or edema. DP pulses 2+ bilaterally. Sensation intact. 

Neurological: patient is able to ambulate normally, finger to nose normal. Sensation to face intact. Jaw strength, facial movements, shoulder shrug, EOMIs with no nystagmus. 

Labs 5/4: 

1. BMP and electrolytes: Na 138, K 3.5, Cl 100, CO2 27, BUN 25, Cr 3.79, glucose 68, Ca 8.3, anion gap 11
2. CBC: WBC 8.75, RBC 3.65, Hgb 10.3 Hct 32.6, MCV 89, MCH 28.2, MCHC 31.7, platelets 262
3. Coagulation panel: aPTT 32.3, PT 12.4, INR 1.0
4. Covid Liat: negative 

Assessment: 

69-year-old female with PMH of ESRD on dialysis (left upper extremity fistula), type 2 DM, hypertension, right sided breast cancer s/p lumpectomy, HCV cirrhosis s/p liver transplant presented to the ED with abdominal pain. She was admitted to step down and for acute abdomen. Pain resolved overnight and diagnostic imaging was negative for SBO or free air in the peritoneal space, no acute abdominal pathology. Increased work of breathing correlated with imaging findings and leukocytosis the patient was diagnosed with pneumonia and treated. She is now hemodynamically stable and was downgraded to red team for further management 

Plan: 

# Respiratory distress secondary to pneumonia:  

1. Leukocytosis- downtrending monitor WBC and fever
2. Bilateral lower lobe consolidations on imaging, increased work of breathing 
3. s/p cefepime 2000 mg X1 dose, levofloxacin 750 mg X1 dose 
4. Continue meropenem 500 mg daily
5. Continue vancomycin 750 mg after HD
6. Continue azithromycin for a total of 5 days
7. Continue oxygen with nasal cannula, monitor pulse oximetry 
8. Blood cultures negative to date (collected 5/2/21)

#abdominal pain associated with nausea

1. Most likely due to lower lobe pneumonia 
2. Diagnostic imaging negative for any acute abdominal pathology 
3. Pain currently resolved, appetite returned  

#Hypertension: 

1. Well controlled 127/60 this AM
2. continue home nifedipine 30 mg daily orally 

# Diabetes mellitus: 

1. Well controlled, blood glucose 68 this AM 
2. continue levemir 6 Units daily. Discharge on home medications. Monitoring finger stick 

# ESRD on HD via AV fistula (elevated BUN and Cr)

1. Continue HD 
2. Continue sevelamer 800 g TID

#Decreased Hgb and HcT (10 and 32)

1. Likely due to ESRD, Monitor CBC 
2. No transfusion at this time 

# Right sided breast cancer stage I s/p lumpectomy: 

1. Follow up with outpatient oncology after discharge

# History of liver transplant s/p HCV:

1. Continue tacrolimus 1 mg Q12 hours
2. GI follow up after discharge 

# DVT prophylaxis: 

1. SQ heparin 

# Diet: heart healthy diet, 2 gm of Na, 300 mg Chol, <75gm of fat, 70gm protein, low phosphorus 

Differential diagnosis: 

1. Pneumonia due to underlying lung disease from Covid-19
2. Community acquired pneumonia 
3. Pneumonia due to immunosuppressed state (DM, tacrolimus, ESRD)
4. Abdominal pain due to lower lobe pneumonia