I’m doing quite well most of the time, with occasional spells of very mild shortness of breath



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77 Year Old Female-Sarah
History and Physical

(Baseline)


Chief Complaint: “I’m doing quite well most of the time, with occasional spells of very mild shortness of breath.”
HPI: 77-year-old female. She has been treated for hypertension for several years, and has always been compliant with her medications. Her follow up in your office has been as you recommend. She seems to need more and more attention from her perspective because of occasional spells of a “feeling of weakness” that is very mild and last about 5 seconds or less. She does not want this looked into because it is so unproblematic. She was hospitalized once 4 years ago with a mild MI. She did well with medical treatment. Her angiogram did not indicate any significant lesions in need of interventional therapy. She does not have any episodes of angina. She doesn’t get around as well as she used to, but says that she is simply getting old, and out of shape.
Past Medical History:

Surgeries: T and A as a child

Hospitalizations: MI - 4 years ago.

Chronic Medical conditions: MI, HTN, DJD (knees)

Psychiatric Illnesses: minor bout of post-partum depression after her last child

Injuries: fractured right ankle after falling while painting the house 10 years ago

Childhood Illnesses: chickenpox and mumps

Immunizations: patient is unsure and records are not complete in this area

Medications: Atenolol 25 mg tab, one p.o. b.i.d.

  1. Isosorbide dinitrate 20mg tab, one p.o. q day.

  2. Lasix 20 mg tab, one p.o. q day.

  3. NTG .4 SL tabs prn. (No use)

  4. ASA 325 mg tab, one p.o. q day.

  5. Tylenol 325 mg tab, one or two p.o. q 8 hours prn. (Uses about one or two per day for knee pains.)

Allergies: Erythromycin

Habits:

Diet: well-balanced diet

Exercise: Twice daily walks until the last year. In the last year she has 3X/wk walks.

Alcohol Use: none

Drug Use: none

Tobacco Use: “casual smoking” for two years age 18 to 20.

Coffee/caffeine Use: 3 cups of coffee per day.

Steroids/transfusions/radiation: none reported

Travel: She has traveled to Europe several times with her husband during their early retirement. Last trip was over ten years ago. She also visited her sister who lived in Panama many years ago.

Gynecologic History: Gravida III Para 3-0-0-3 Vaginal Deliveries. Last Pap Smear age 70. Last Mammogram-one year ago. LMP age 53


Family History: Father 77 MI, Hypertension, Obesity

Mother 75 Rheumatoid arthritis

Sister with hx of breast cancer.
Social History: Housewife for all of her life. Married for 55 years in a good relationship. Husband, Sam, is a retired grocer in the community. No abuse concerns. Three children living. One daughter had had breast cancer. Son has had colon cancer. Second son with ASHD and hyperlipidemia. She is active in the community with volunteer activities at a local nursing home. Finances are not a problem, but she is frugal to ensure that things remain this way.
Review of Systems:

General: No fever chills, night sweats, or weight change.

Skin: Losing some hair in a normal aging baldness pattern for her age, no skin changes

HEENT:


Head: No history of trauma, headaches, trauma, dizziness, or seizures

Eyes: No change in vision or diagnoses of glaucoma. No field changes.

Ears: Mild HOH. No tinnitus, or vertigo.

Nose: No epistaxis, fracture history, or running of the nose.

Mouth and Throat: No sores, pain. She wears well fitting dentures for several years. Neck: No masses, goiter or pain

Breasts: No lumps, discharges or pain

CV: No chest pain, PND, or orthopnea. Occasional very mild short lived episodes of weakness. No use of nitroglycerine since her discharge from the hospital for her MI. No dyspnea on exertion.

Respiratory: No cough, SOB, wheezing, sputum or hemoptysis

GI: No nausea, vomiting, diarrhea, black or bloody stools. Occasional constipation for which she takes an over the counter laxitive. This occurs about once per month.

GU: No dysuria, hematuria, or increased frequency

Reproductive/Sexual History: Menopause at “the usual age.” This was relatively uneventful for the patient.

Hematologic: No bleeding disorders or lymphadenopathy, She bruises more easily than she used to, but states this is because her skin is getting thinner. . No hx of anemia or transfusions

Endocrine: No polydipsia, polyuria or polyphagia, no hot or cold intolerance noted.

Musculoskeletal: Occasional soreness to the knees, particularly with much walking. This has been getting worse over the last few years.

Emotional: Patient was treated post-partum after her last child for post-partum depression for one year. No further history of psychiatric problems, depression or abnormal adjustments to life emotional changes.


PHYSICAL EXAMINATION
General Appearance: alert, oriented 77 year old female in no acute distress
Vital Signs: BP 158/88 P 56 R 16 Weight 182 # Height 5’1/2”
Skin: no abnormal moles or lesions noted

Head: no abnormalities of the scalp

Eyes: (CN 2,3,4,6) PERRL, EOMI, normal visual fields by confrontation

Ears: (CN 8) mild reduction in hearing with whisper test, TMs negative, normal canals

Nose: no deviations noted, no evidence of epistaxis.

Oral Cavity: (CN 5,7.9.10,12) posterior pharynx normal, no hoarseness is present, tongue midline and moves from side to side

Neck/Lymph Nodes: no thyromegaly, no carotid bruits, no palpable lymphadenopathy

Chest: clear to auscultation, with mildly reduced breath sounds throughout

Breasts: no nodules or cysts palpated and no lymphadenopathy in the axilla bilaterally

Cardiovascular: Rate 56 without murmurs S3 or S4, occasional skipped beat

Abdomen: BS present, soft without masses

Back: normal flexion and extension, unable to touch toes

Extremities: Bilateral knee enlargement. No soft tissue swelling. No errythema or warmth. No pretibial edema.

Genitalia/Rectal: vaginal walls without abnormalities, cervix-multiparous without lesions, no adnexal masses, no masses on rectal exam-a few small asymptomatic hemorrhoids

Musculoskeletal: (ROM/Strength) Strength 4/5 upper and lower extremities. Difficulty rising from a squatting position due to bilateral knee pain.

Neurological: Reflexes 2/4 upper and lower extremities, no sensation abnormalities, coordination intact to finger to nose and rapid alternating movements, mild bilateral tremor (resting and active), Gait steady but evidence of knee pain consistent with gait, Negative Rhomberg, Babinski not present. Mental status normal to judgement, orientation, memory (recent and remote), intellect, appearance, and calculations.
Assessment:


  1. S/P MI

  2. HTN

  3. DJD

  4. Mild weakness spells of unclear etiology

  5. S/P T and A

Plan:


1.EKG, Chest X-rays, Electolytes, CBC, glucose, TSH, fasting lipid profile with follow up visit after all tests returned in a few days.

2. Schedule Mammogram

3. Notify the office of any changes

S. Walker MD

SOAP NOTE 3 MONTHS LATER:
S: Patient is seen three months after last visit. At her last visit her only problem was that of mild infrequent short lasting episodes of weakness. EKG, and labs were all normal at the time except for a slight bradycardia. Patient declined further work up and has reported no interim problems until three days ago. She states three days ago that she notices swelling in her legs and problems sleeping. She wakes with shortness of breath feeling a little panicked feeling. She gets better when she sits up for a few minutes. She states she is compliant with all of her medications.

Atenolol 25 mg tab, one p.o. b.i.d.



  1. Isosorbide dinitrate 20mg tab, one p.o. q day.

  2. Lasix 20 mg tab, one p.o. q day.

  3. NTG .4 SL tabs prn. (No use)

  4. ASA 325 mg tab, one p.o. q day.

Tylenol 325 mg tab, one or two p.o. q 8 hours prn. (Uses about one or two per day for knee pains.)

O: Temp: 35.0 Pulse: 46 Resp: 28 BP: 188/96 Weight: 195 pounds

Alert, in moderate distress, obviously short of breath, mildly anxious.

HEENT: PERRL, EOMI, TMs negative, oral pharynx negative, neck supple, thyroid non palpable.

CV: Heart regular. S-3 present, no S-4, no murmur, +JVD

Lungs: Crackles in the lower one half of the posterior fields.

Abdomen: Soft with normal bowel sounds.

GU/Rectal: normal examination

Neuro: CN II-XII intact, Motor intact, sensation intact, coordination intact, Babinski not present bilaterally, Negative Rhomberg, Gait normal but slow.

Extremeties: pitting edema to mid tibia present bilaterally.


Labs and other tests:

EKG: Third degree heart block

Electrolytes, glucose, and LFTs all normal

CBC normal

CXR: cardiomegally, Kerly’s B lines present, small bilateral pleural effusions.

0xygen saturation 91% on room air.

A: CHF – Acute secondary to bradycardia

S/P MI


DJD history

  1. Admit, Rule out MI labs, serial EKGs, add ACE inhibitor, Loop diuretics, oxygen therapy, Evaluation for pacemaker, Monitor, ICU, see admit orders on hospital record.

POST HOSPITAL SOAP NOTE


S: Patient is seen one week post hospitalization for CHF secondary to bradycardia. MI was ruled out. While hospitalized patient was diuresed, and a pacemaker was placed. Patients response to the pacemaker was significant. She was released after 5 hospital days in satisfactory condition with a weight of 183 pounds and no edema. Her Oxygen saturation at discharge was 97% on room air. Since being at home she has been compliant with medications and is feeling well. No chest pain/PND/Orthopnea. No edema. No shortness of breath. Her ability to exercise is back to her baseline. No cough/hemoptysis. GI review negative.
Patient notes that the addition of the new medication, Enalapril, is cost prohibitive and wonders what she might do about it. She did purchase it, but would like to know if there is a less expensive alternative.
When asked how she’s doing with all of her medications she says it’s difficult because her husband is becoming quite a task to take care of. She says that he used to be the “keeper of the medications” but with his prostate cancer treatments, and COPD problems he can’t help her much anymore, and in fact she has to help him with her medications. Her daughter she says has always been very helpful, but notes that this is becoming a problem as well. She says her daughter looks exhausted coming over to the house all of the time taking care of her and her husband. She thinks this is because her daughter is such a good mother and has her own kids to take care of and on top of it works part time. She believes she and her husband get most of their medications most of the time, but she says it’s exhausting getting through all of the chores of the day. She’s thought about hiring someone to come and help, but when she looked into it the cost was more per hour than her husband used to make in a week when he was younger. She is a bit tearful talking about all of this.

Medications:

Enalapril 5mg tab, one p.o. q day.

Atenolol 25 mg tab, one p.o. q day.



  1. Isosorbide dinitrate 40mg tab, one p.o. q day.

  2. Lasix 40 mg tab, one p.o. q day.

  3. KCL – 20 mEq, p.o. q day

  4. NTG .4 SL tabs prn. (No use)

  5. ASA 325 mg tab, one p.o. q day.

Tylenol 325 mg tab, one or two p.o. q 8 hours prn. (Uses about one or two per day for knee pains.)

O: Afebrile, HR 72 and regular, BP 138/72, Respiratory rate 18, weight 186 pounds

Alert, in no acute distress

HRRR, no S-3, no S-4, No murmur, No gallup, No rub

Lungs – mild reduction in breath sounds. No crackles, rales, rhonchi, wheeze.

NBS


No edema

Neuro exam non focal.

Mental status exam: Dress in the past has been very fastidious. She has a couple of small difficult to see food stains on her sweater today – this is a change for this patient.

EKG – paced rhythm at rate of 72/min

Lytes, BUN, Creat, LFTs, CBC all normal.

CXR – mild cardiomegally, otherwise clear. Pacemaker and proper wire placement noted

A: 1. S/P MI

2. Recent hospitalization for CHF – no signs of recurrent CHF-Pacemaker



  1. DJD

  2. Mental status changes.

5. Family stressors of failing health, less available home helpers, and financial difficulties.

TOPICS FOR DISCUSSION


1. Do you agree with the assessment of Sarah’s health issues? Any additions?

2. What is your plan in addressing her acute conditions and chronic areas of concern?

3. What preventive issues would you want to include in your care of Sarah?

4. How would you assess Sarah’s living conditions and meet her desire to be independent?

5. What risks to her health exist in her home situation?

POST DISCUSSION


P: 1. No change in therapy. Address potential compliance issues.

  1. Return visit in two weeks for an office visit.

  2. Tylenol PRN.

  3. Mini mental status exam at next visit, B-12, Folate, TSH,

  4. Review of medication usage with home health care RN, consider etiology to be increased stress of increased responsibility for self and husband secondary to husbands failing health and daughter’s personal stresses. Consider nursing home in the future and/or assisted living. Consider help in the home pending financial consideration evaluation with social work.

6. Home visit from RN to evaluate home situation. Consideration of nursing home or assisted living should be made.

7. Social worker contact to assist with finances.



8. Samples as available to help with financial situation.


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