Academic H & P note
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ANP_650_H_P_wk_7.docx.pdf
ANP- 650
Academic Clinical History and physical Note
Student Name: Theresa Davis-Bates Date: 12-10-2019
PATIENT PROFILE Patient Initials: B. M. DOB: 10-18-1927 Sex: Female Race: Hispanic Marital Status: widowed Admit Date: 12-06-2019 Allergies: NKDA Chief Complaint: Dizziness, syncope
History of Present Illness: This is a 92-year-old Hispanic female who was brought into ER with CC of dizziness and syncope. She was washing dishes at her nephew’s birthday party when she fell. Patient reports the dizziness has been going on for a year, but this is the first time she has fallen and blacked out for a second. Patient reports she woke up when she hit her head. Patient denies any nausea, vomiting, headaches, chest pain, or recent ear infections. She also reports her blood pressure has been elevated, and when she takes her medication, standing makes her dizzy. I had patient stand as if she was going to the bathroom, and she became dizzy right away. Patient also reports bright red blood in stool per rectum with history of hemorrhoids. Reports history of chronic constipation. Denies abdominal pain or discomfort, no loose stools. HGB stable-11.3. Patient has been hospitalized for severe constipation in the past.
Past Medical History: Type 2 diabetes Mellitus non-insulin dependent Hypertension Hyperlipidemia COPD Chronic constipation Hemorrhoids
Surgical Medical History: Right leg surgery: Pt does not know what type of surgery Bladder lift
Medications: ProAir 90mcg/inh 1 puff inhaled orally BID Atorvastatin 20mg 1 tab PO daily Benazepril 10mg 1 tab PO BID Lactulose 10g/15ml PO 30ml BID PRN- Constipation Meclizine 25mg 1 tab PO Q8h as needed- dizziness Pantoprazole 40mg 1 tab PO daily Psyllium 3.4g/7g oral powder daily
Social/Personal History: Patient lives with sister and family. Sister is caregiver. Widowed. Denies smoking, recreational drug use, or use of alcohol. DNR status
Family History: Mother and brother: Diabetes Unknown if anyone had CAD or cancer
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ANP 650 Clinical History and Physical Note
Review of Systems: Constitutional: Denies fever/chills, weight gain or loss, or fatigue Head: Positive head pain from fall, Denies lightheadedness, confusion Eyes: Denies vision changes or blurriness ENT: Positive hard of hearing and vertigo. Denies tinnitus, nasal drainage or stuffiness, denies any sore throat or
swallowing issues Skin: Denies skin changes or rash, no pruritis, bleeding or bruising Cardiac: Denies chest pain, palpitations, edema, or PND Pulmonary: Denies SOB, wheezing, sputum production, or cough GI: Positive bloody stools and constipation. Denies dysphagia, abdominal pain, N/V/D GU: Positive urgency, hx bladder surgery. Denies any dysuria, incontinence, polyuria, or hematuria Neurology: Positive dizziness. Denies focal weakness, num/ting, neck stiffness, seizures or stroke Musculoskeletal: Positive back pain. Denies joint pain, swelling, arthralgia Psychiatric: Denies stress, anxiety, or depression
Vital Signs: BP: 180/51, HR: 73, RR: 16, temp: 98.1, O2 sat: 95% RA (12-07-19 0800) 12-07-19 1230pm: Orthostatic BP: lying- 122/68; standing- 82/56 (+)
Measurements: Weight: 64kg, Height 155cm, BMI 27
Physical Exam: General: Normal hygiene, affect, no apparent distress, appears younger than age Head: no scars, deformities, bumps, or open wounds Eyes: Pupils equal, round, and reactive to light. No icterus ENT: hard of hearing, no nasal drainage, lymphadenopathy, exudate. Trachea midline Cardiac: heart tones normal, regular rate/rhythm, no murmurs/rubs/gallops, no edema Pulmonary: no wheezes/rales/rhonchi, clear to auscultation, no distress, symmetrical chest wall expansion GI: BS active/normal, no bruits, non-tender/distended Genitourinary: no Foley catheter, no UTI Skin: no rashes, bruises, or open wounds Neurology: bilateral grip strong, normal sensation, tongue midline, and normal movements; unsteady gait/standing MSK: normal ROM to upper and lower extremities Lymphatics: no lymphadenopathy Mental status: awake, alert, oriented x 3, obeys command, communicate appropriately
Labs (12-07-19): CBC: WBC 6.8, RBC 3.52, H/H 11.3/33.1, MCV 94.0, MCH 32, PLT 164, Chemistry: NA 140, K+ 4.0, Cl 106, BUN/Cr 43/1.58, Bili 1.5, Lac 1.20, Mg 2.21, Co2 24, AGAP 14, Glu 115, ALT
13.0, AST 22, lipase 23, T-pro 7.50, GFR 30.6 Cardiac: troponin I 0.050 Coags: PT 10.8, INR 1.0 Occult stool: negative
Imaging (12-06-19): CXR 1 view: Impression- Stable chronic post-inflammatory changes. No acute distress. CT brain w/o contrast: Impression- Age-related senescent changes. No acute intracranial abnormality. Sinusitis.
EKG NSR with rate 80, no St elevations or depressions, T-wave inversion, R. BBB
Assessment/Plan: DDx:
Syncope secondary to orthostatic hypotension o Orthostatic BP standing dropped to 82/56. o Orthostatic hypotension often occurs in the older population, > 65 yrs. Hardening of the arteries develops as
age increases; this makes it more difficult for blood vessels to quickly adapt, as needed. As well as the other
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ANP 650 Clinical History and Physical Note
progressive diseases that are associated with orthostatic hypotension becomes worse in the elderly (MedicineNet, 2019). The patient is 92 y/o.
o Blood loss, dehydration, and anemia are a few of the most common reasons for orthostatic hypotension (MedicineNet, 2019).
o High blood pressure medications can result in orthostatic hypotension Bleeding internal hemorrhoids (K62.5):
o Being constipated and straining can damage the surface hemorrhoids, causing them to bleed. This could happen with both internal and external (Healthline, 2018). Pt had blood in stool and a history of both hemorrhoids and chronic constipation.
Dx/Plan: Consults: Cardiology: To manage hypertension and orthostatic hypotension Orthostatic hypotension due to Syncope episode (I95.1)
o Midodrine 2.5mg 1 tab PO TID: short-acting pressors to assist in hypotension. Hypertension is a risk factor for orthostatic hypotension and both common in older adults. While certain hypertensive medicines can trigger orthostatic hypotension, total withdrawal is not appropriate (Epocrates, 2019).
o Decrease Benezapril to 10 mg 1 tab daily for SBP >150: according to the Journal of Hypertension, target BP for the elderly >60 years of age is 150/90 (Currie & Delles, 2018). However, this number is not set in stone, and it depends on the frailty of the patient. Careful use of antihypertensives like ACEI or ARBs, and avoiding medicines that are likely to cause orthostatic hypotension, for instance, alpha-blockers, diuretics (Epocrates, 2019).
o IVF for hydration: Dehydration is one of the common causes of orthostatic hypotension, and treating the underlined cause is recommended. The patients Creat 1.58 (was 1.69 on admission) and liver enzymes are slightly elevated; this could be due to dehydration.
Acute kidney injury (N17.9): Creat 1.69 on admission 12-06-19, then 1.58 next blood draw 12-07-19, liver enzymes slightly elevated.
o IVF for hydration, as mentioned above. Signs and symptoms of dehydration include postural dizziness and hypotension, fatigue, chest pain, and last but not limited to tachycardia (Epocrates, 2019).
o Monitor labs CMP and CBC: to monitor Bun/cr, H/H, and lytes (Epocrates, 2019). Dehydration (E86.0):
o Same plan as above. Bleeding internal hemorrhoids (K62.5): Pt reported bright red blood in stools.
o Occult stool (-) o Stool softener to prevent straining. Being constipated and straining can damage the surface hemorrhoids,
causing them to bleed. This could happen with both internal and external (Healthline, 2018). Pt had blood in stool and a history of both hemorrhoids and chronic constipation
Type 2 DM (E11.9) o Accu checks AC/HS with insulin sliding scale. Although patient diabetes is well controlled and does not take
diabetes medication, hospital admits, and acute illness causes stress, which increases glucose levels. CKD 3B due to diabetes (N18.3)
o Continue ACEI: studies indicated w/ advance CKD and stable HTN, antihypertensives treatments with ACEI/ARBs reduce the chances of long-term dialysis and lower mortality risk (Medscape, 2019).
o Keep blood glucose controlled. To delay or slow the progression of CKD. Hypertensive CKD w/ stage 1 through stage 4 chronic kidney disease, Type 2 DM (I1.29)
o Benazepril 10mg 1 tab daily if SBP >150. According to Currie & Delles (2018), the elderly > 65 can maintain BP of 150/90.
o Vital signs Q4H: monitor BP Anemia secondary CKD (D63.8).
o Labs: CBC in AM. Last HGB 11.3. Stable
Disposition and Expected Outcomes Admit to telemetry unit: to continuously monitor cardiac rhythm and Q4 vital signs Counsel patient and patients family regarding diagnosis, diagnostic reports, treatment plan I discussed with patient the planned work-up and the need to follow up as outpatient with PCP and cardiology when
discharged
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ANP 650 Clinical History and Physical Note
The expected outcome will be to discharge home within a couple of days, if assist readily available in the home, or admit to rehab for PT/OT and to monitor blood pressure. The patient understands the plan of care.
Health education/ health promotion/ disease prevention (RHIhub, 2019). Identify opportunities for health promotion and education Understand the potential barriers Know what is easily accessible to the patient and the patient population. Understand the cultural and social issues Resources and sustainability
Ethical and Geriatric considerations Respect for the patient's autonomy Providers should adequately inform them of their illness and treatment options Patients of age must have thinking capacity to give informed consent When any of these ethical principles are overlooked, a clinician may be at risk for neglect or abuse. Clinicians should prevent elder neglect and abuse (ASA, n.d).
References
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ANP 650 Clinical History and Physical Note
American Society in aging [ASA] (n.d). Ethical Caregiving and Protecting Elders. Retrieved from
https://www.asaging.org/blog/ethical-caregiving-and-protecting-elders
Curries, G. & Delles, C. (2018). Blood pressure targets in the elderly. Journal of Hypertension 36(2). Retrieved from
https://journals.lww.com/jhypertension/Fulltext/2018/02000/Blood_pressure_targets_in_the_elderly.5.aspx
#pdf-link
Epocrates (2019). Orthostatic hypotension; dehydration; and CKD. Retrieved from https://online.epocrates.com/
Healthline (2018). How to manage bleeding hemorrhoids. Retrieved from
https://www.healthline.com/health/bleeding-hemorrhoid
MedicineNet (2019). Orthostatic Hypotension (Low Blood Pressure When Standing). Retrieved from
https://www.medicinenet.com/orthostatic_hypotension/article.htm
Medscape (2019). Chronic kidney disease. Retrieved from https://www.medscape.com/nurses
Rural health information hub [RHIhub] (2019). Health promotion and disease prevention. Retrieved from
https://www.ruralhealthinfo.org/toolkits/health-promotion/3/challenges
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