History and Physical with Admission Note
Date of Birth: 06/13/1945
Age: 67
Sex: Female
Date of Admission: 10/02/2012
Chief Complaint: Increasing shortness of breath x 3 days
History of Present Illness: Patient is a 67-year old female with a history of advanced terminal COPD. She
began having increasing shortness of breath since Friday, but did not seek medical care. The shortness
of breath kept getting worse and she began to develop a dry cough Monday night. She used her Advair
inhaler with minimal relief. Today, her shortness of breath continued to advance to the point that she
called the ambulance. When EMS arrived her O2 saturation was 84% on room air. When she arrived in
the emergency department she was hypoxic and in respiratory distress. She was put on a CPAP and
taken to her emergency room and seen by the emergency room physician. She was treated with SoluMedrol and SVN treatment. Following treatment, she was still short of breath. Upon examination
significantly diminished air movement was noted. Attending physician was then called to admit patient.
The patient has been seen multiple times for episodes of COPD exacerbations. She has been instructed
to seek medical care when increase shortness of breath is first noticed, but she has been non-compliant.
Pertinent Past Medical History
1. Terminal COPD
2. History of recurrent bronchitis
3. History of respiratory failure
4. Smoking: She has been instructed many times to quit, however does not.
Pertinent Family History:
Father passed at the age of 75 of heart failure
Pertinent Social History
Patient has a significantly positive history for tobacco use. Patient claims to smoke 1 pack per
day for past 40 years. Patient denies alcohol or illicit drug use. Patient does not attempt to exercise,
and it is thought that she rarely leaves her apartment.
Medications: Advair 115/21 inhaler, 2 puffs BID
Tylenol 325mg, 2 tablets every 6 hours as needed for occasional headaches
Allergies: Patient denies any known allergies.
Review of Systems:
General: Patient denies weight or appetite change, fever, chills, night sweats, or fatigue
Head: Occasional headaches-unchanged in years, denies trauma, or changes in vision or hearing
Skin: Patient denies any changes in skin, hair or nails, also denies any rashes or itching
Eyes: Patient states that she does occasionally get dry eyes, attributing it to pollution from the road
coming into the window of her apartment. Patient does not wear glasses or contacts, has had no
blurring or decrease of visual acuity
Ears: Patient states she believes she has occasional vertigo, however has never sought out medical care
for this. Patient does not wear hearing aid and has not experienced hearing loss or ringing in ears
Nose: Patient claims to have constant “runny nose,” denies sneezing or allergies
Mouth, Throat, Neck: Patient denies sore throat, lesions in mouth, hoarseness or lumps or swelling of
neck
Cardiovascular: Patient denies chest pain, tightness, palpitations
Respiratory: Positive for terminal COPD, multiple admissions for bronchitis and respiratory failure.
Patient claims to have constant shortness of breath, increasing with walking or bending over.
Gastrointestinal: Negative for abdominal pain, nausea, vomiting, diarrhea, and constipation
Genitourinary: Patient denies pain with urination, blood in urination, history of urinary tract infections
or kidney stones
Central Nervous System: Negative for stroke, TIA, dizziness, or syncope
Musculoskeletal: Patient denies weakness, decrease in muscle strength, difficulty walking
Extremities: Negative for numbness, tingling, decreased strength or sensation
Hematological: Patient denies history of DVT, PE, knowledge of bleeding or clotting disorder, or bruising
easily
Medical History
Childhood: Patient denies any childhood illnesses, uncertain if she had chicken pox
Adult Immunizations: Patient has not received flu vaccine this year, has previously received pneumonia
(9/2010) vaccine or shingles (11/2011) vaccine
Past Medical History:
1. Terminal COPD
2. History of recurrent bronchitis
3. History of respiratory failure
4. Hypertension
5. Hyperlipidemia
6. Smoking
Hospitalization History:
1. Birth of 9 children
2. For all surgical procedures (see surgical history)
3. Admitted 3 times for CODP exacerbations/Bronchitis, all within last 7 years
Surgical History:
1. Laparoscopic Cholecystectomy: 1996
2. Hysterectomy : 1991
3. Surgical knee repair: 1979
Family History:
1. Mother: deceased, uterine cancer
2. Father: deceased, heart failure
3. Siblings: 2 brothers, does no communicate with, last heard they were in good health
4. Children: Patient has 9 children, one deceased from auto accident, otherwise all alive and in
good health.
Social/Psychiatric History:
She lives alone and claims to have distanced herself from the majority of her family. She believes the
trouble with her family is related to the decisions she has made regarding her health and life style
Patient claims that she has had trouble with anxiety and depression in the past, but she has never been
treated medically. Patient also admits to 4-6 caffeinated drinks per day.
Physical Examination
Vitals: Blood Pressure: 123/92, Pulse 127, Respirations: 28, O2 saturation: was 84% on room air when
EMS arrived at home, after SVN treatment and 2L oxygen via nasal cannula improved to 96%
General: The patient is awake, alert, orientated, and appears to be in moderate distress, lying in bed
Skin: Warm and dry, no scars, rashes, or bruises
Head: Atraumtic and normocephalic
Eyes: Pupils are equal and reactive to light, extraocular muscles intact
Mouth: Poor dental hygiene, few teeth remaining, no bleeding or ulcers
Neck: No tracheal deviation, no masses detected on thyroid, no lymphedema
Chest: Increased AP diameter
Breast: No changes in color, symmetry, lumps or tenderness
Lungs: Significantly diminished breath sounds bilaterally with diminished air entry. Minimal expiatory
wheezing detected
Heart: Negative for rubs, gallops, clicks, or murmurs, regular rhythm, S1 and S2 detected, tachycardia
Abdomen: Soft, positive bowel sounds x4, non-tender, no organomegaly
Extremities: No edema or cyanosis, no calf tenderness
Peripheral Vascular: Varicose veins observed on lateral thighs. Carotid, radial, posterior tibial, and
dorsalis pedis all +2 and equal bilaterally
Neurological: Patient awake, alert, and oriented, no focal deficient detected.
Assessment:
1. Acute COPD exacerbation
2. Bronchitis
3. Pneumonia
4. Common cold/flu symptoms
5. Congestive Heart Failure
6. Lobar Atelectasis
Plan: Admit the patient to the medical floor. See admission note.
Christie E. Slottje, PA-S
Christie E. Slottje, PA-S
10/2/2012 9:15 am
Admission orders
Patient Name: xxxxxxxxxxx
DOB: 06/13/1945
Sex: Female
Admit to: Medical Floor, Lock Have Hospital
Admitting Physician: Dr. Raj Patel
Diagnosis: Shortness of breath with cough, advanced terminal COPD
Condition: Stable
Vital Signs: Blood pressure, pulse, respirations, O2 saturation, and temperature every 6 hours
Activity: As tolerated
Nursing Care:
Oxygen: 2L nasal cannula, titrate to keep O2 saturation above 92%
Weight on admission, then everyday at same time
Diet: low salt, low fat diet
Ins & Outs: NSS with 10KCl at 100 cc/hour
Studies: Check that all studies were completed as ordered in Emergency Department
Blood cultures and sensitive
Sputum cultures and sensitivity
Medications: Home medications:
1. Advair 115/21 inhaler, 2 puffs BID
2. Tylenol 325mg, 2 tablets every 6 hours as needed for occasional headaches
Given in ER:
1. Solu-Medrol
2. SVN treatment
Medications on Floor:
1. Continue Home medications
2. Solumedol 60mg IV q 6 hours
3. Levaquin 60mg IV q 4 hours
4. Duoneb q 6 hours
Allergies: NKA
Lines: established #16 in right hand
Special Instructions: none
Christie E. Slottje, PA-S
Christie E. Slottje, PA-S
10/2/2012 9:15 am