CASE STUDY_2
nikkyvu
CASESTUDY_2_HOSPITAL.docxHistory Data:
Chief concern: “ I am here to follow up after hospitalization and decreased tolerance to activity.”
Pertinent PMH: The Patient is a 78-year-old African American female who presents to the office on 10/1/2024 with a complaint of decreased activity tolerance and functional limitations due to her episodes of shortness of breath on exertion for the past three weeks. She denies any recent travel or any sick contact at home or in church. The Patient has PMH of bilateral carpal tunnel syndrome, hypertension (HTN), chronic kidney disease stage four with GFR 15-29 (CKD), insulin-dependent type 2 diabetes mellitus (IDDM2), Congestive heart failure (CHF), and anemia of chronic disease (AOCD). She is a retired schoolteacher; she is mostly home and attends church every Sunday. The patient is currently taking Amlodipine besylate 10 mg tablet by oral route once daily, hydralazine 50 mg tablet, one tab orally two times daily, and carvedilol 25 mg tablet, one tab orally twice daily for HTN. Acetaminophen 500mg tablets, one tablet orally every q8hrs PRN for pain, Gabapentin 100 mg tablet, one tablet orally TID for pain, Vit D2 1.25 (50,000 unit) by oral route once weekly for Vitamin D deficiency, omeprazole DR 20 mg capsule for GERD, Aspirin EC 81 mg tablet: take one tablet (81 mg) by oral route once daily, torsemide 20 mg tablet: take two tablets (20 mg) by oral route once daily for edema, Verquvo 5 mg tablet, film-coated, one tab once daily for CHF; Crestor 10 mg tablet: take one tablet (10 mg) orally once daily for HLD. Januvia 25 mg tablet, one once a day, farxiga 10 mg tablet, take one tablet (10 mg) orally once daily, Basaglar 100 units/ml KWIKPEN 10 units daily at bedtime for DM. Allergies: NKDA. The Patient denies drug, tobacco, or alcohol use. Both parents have passed. The Patient's mother had a history of DM and HTN and passed away at 85 years old, and the father had an hx of HTN and passed away at age 70 years. The Patient has two brothers who have medical hx of HTN and DM and are still living. She has two sisters. One is still living with HIV; the second sister died of colon cancer. She is a widow whose husband passed away three months ago from prostate cancer; she has six grown children who live in different states. Her last BM was this morning. She is up to date on all her vaccines. She has taken all three COVID-19 vaccines from Pfizer; she also received the bi-valent booster, and a flu vaccine was given during this visit.
Family history:
-The Patient's mother had a history of DM and HTN and passed away at 85 years old, and the father had an hx of HTN and passed away at age 70 years from congestive heart failure
- The Patient has two brothers who have medical hx of HTN and DM and are still living. She has two sisters. One is still living with HIV; the second sister died of colon cancer.
- She is a widow whose husband passed away five years ago from prostate cancer
She has six grown children who live in different states.
Social history:
-She is a widow whose husband passed away five years ago from prostate cancer
- She lives in a senior apartment building and has a home health aide assistant that helps with activities of daily living;
-She is a Pentecostal Christian; she goes to church every Sunday
She is not a sexually active, non-smoker, or non-ETOH user.
