History and Physical with Admission Note
Date of Birth: 03/13/1937
Age: 76
Sex: Female
Date of Admission: 03/27/2013
Chief Complaint: Increasing shortness of breath and chest pain for 2 days
History of Present Illness: Patient is a 76 year old female who presented to the Emergency
Department at Harrisburg Hospital with a complaint of worsening shortness of breath and chest
pain for the past 2 days. The patient has a history of HIV, smoking history, hypertension,
diabetes and was recently diagnosed with adenocarcinoma of the lung, for which she receives
daily palliative radiation and chemotherapy (last session: 3/11/13). The patient states that she
has had a dull chest ache for the past 6 months and has attributed this to her lung cancer,
however, in the past 2 days the pain has continuously intensified and become sharp and it is
currently a 10/10. The pain is focused over the sternum and radiates to the right side of the
chest and right axilla. The pain is worse with movement and deep inspiration, and is only
relieved by oxycontin. The pain is continuous when the patient is active and at rest. The
patient is more concerned with the shortness of breath that has accompanied the pain. She
states that the shortness of breath began 2 days ago while she was resting in bed. It has
continued to increase in severity to the point that she was “sure she was dying.” The shortness
of breath is not relieved by anything.
Medications:
Pantoprazole 20mg tablet PO daily
Fenofibrate 145mg tablet Po daily
Percocets 5/325mg tablet PO q4-6 hours PRN
Oxycontin 80mg tablet PO q12 hours PRN
Novolog Pen 10 units subcutaneous injection TID (with meals)
Stribild 1 tablet PO daily
Levemir 40 units subcutaneous injection QAM
Levemir 40 units subcutaneous injection QPM
Tricor 160mg tablet PO daily
Albuterol 2.5mg Inhaled solution Q2 hours PRN
Lorazepam 1mg tablet PO Q6 hours PRN anxiety
Allergies: Morphine – Reaction: rash
Past Medical History
1.
Stage 4 adenocarcinoma of the lungs, diagnosed 6/12
2.
HIV positive for 30 years, compliant with treatment
3.
Hypertension, diagnosed 1987
4.
Type 2 diabetes, well controlled (A1C 5.6 in 1/2013) diagnosed 1987
6.
Anemia, diagnosed 1982
7.
Hyperlipidemia, diagnosed 6/1992
Family History:
Father had lung cancer and diabetes when he passed of MI at age of 76. Mother and
father both had hypertension. Mother passed at age of 84 from cervical cancer. The patient
has no history of her maternal grandparents as they disowned her mother and she has never
met them. Her paternal grandfather had hypertension and died of a myocardial infarction at
the age of 65. The paternal grandfather had diabetes which was poorly controlled and prostate
cancer. He died at the age of 67 from pneumonia. She has no siblings and no children. As far
as patient is aware there is family history of stroke, hyperlipidemia, or chronic respiratory
disease.
Social History
She smoked 1 pack per day for 30 years, quit in 2006, denies alcohol or illicit drug
use. She is HIV positive and is compliant with treatment. She does have 1 or 2 caffeinated
beverages a day. She is widowed, as her husband died of HIV related pneumonia 25 years ago.
She has not been sexually active since his death. She is active in the church and is close with a
niece that lives nearby. She does not attempt to exercise. She does eat a healthy diet, including
fruits, vegetables, and whole grains.
Hospitalization History:
1.
Hysterectomy, 11/1982
2.
Lung biopsy, 3/2011
3.
Laparoscopic Cholecystectomy, 7/2002
4.
Admitted 3 times for shortness of breath since 2011, (11/2011, 12/2012, 2/2013)
Surgical History:
1.
Hysterectomy: 11/1982
2.
Laparoscopic Cholecystectomy, 7/2002
3.
Lung Biopsy, 3/2011
Childhood: Patient is aware of chickenpox but is uncertain of any other childhood illness
Adult Immunizations: Patient received influenza vaccine this year (10/2012), pneumococcal
vaccine in 9/2010, and is up to date with tetanus.
Review of Systems:
General: Patient admits to night sweats and chills, denies weight or appetite change, fever or
fatigue
Head: Patient denies headaches, trauma, or changes in vision or hearing
Skin: Patient denies any changes in skin, hair or nails, also denies any rashes or itching, cuts or
bruises
Eyes: Denies dry eyes, blurry vision, change in vision, does not wear glasses or contacts
Ears: Patient denies hearing loss, discharge, pain, ringing in ears, does not wear hearing aids
Nose: Patient denies rhinorrhea, sneezing, stuffiness, or congestion
Mouth, Throat, Neck: Patient admits to recurrent oral thrush; denies sore throat, hoarseness or
lumps or swelling of neck
Cardiovascular: Patient admits to chest pain as per HPI, denies palpitations, feeling of heart
racing, murmur
Respiratory: Patient admits to shortness of breath and adenocarcinoma as per HPI; denies
cough, wheezing, coughing of blood or sputum
Gastrointestinal: Patient denies abdominal pain, nausea, vomiting, diarrhea, and constipation,
melena, or rectal bleeding
Genitourinary: Patient denies pain with urination, blood in urination, also denies history of
urinary tract infections or kidney stones
Central Nervous System: Patient denies history stroke, TIA, dizziness, or syncope, tingling or
parenthesis
Musculoskeletal: Patient admits to difficulty ambulating and weakness due to shortness of
breath, denies decrease in muscle strength, or decrease in range of motion
Extremities: Patient denies numbness, tingling, decreased strength or sensation
Hematological: Patient denies history of DVT, PE, knowledge of bleeding or clotting disorder, or
bruising easily
Physical Examination
Vitals: Blood Pressure: 104/82, Pulse 96, Respirations: 16, O2 saturation: 99% on 2L nasal
cannula, 84% on room air, Weight: 71.3 kg, Height: 68 inches, BMI: 23.8
General: The patient is an African American female, awake, alert, orientated, lying in bed with
obvious labored breathing
Skin: Warm and dry, no scars, rashes, or bruises, no pitting or discoloration of nails
Head: Short and coarse hair alopecia hair, NC/AT
Eyes: PERRLA, EOMI
Mouth: Dentures present, pink and moist oral mucosa, thrush on tongue, no other lesions
Neck: No tracheal deviation, no masses detected on thyroid, no lymphedema
Chest: Labored breathing including use of intercostal muscles, AP diameter ratio 1:2
Breast: No changes in color, symmetry, lumps or tenderness
Lungs: CTAB with slightly diminished breath sounds on the right side. Percussion tympanic in all
lung fields, PMI visible and palpable in 5th intercostal space midclavicular line. No wheezing,
crackles or rales present
Heart: Regular rate and rhythm, S1 and S2 detected, negative for rubs, gallops, clicks, or
murmurs.
Abdomen: Soft, positive bowel sounds x4, non-tender, with 3 small faded surgical scars
corresponding to laparoscopic cholecystectomy. Negative for masses, bruits, and
organomegaly
Musculoskeletal: 5/5 strength, normal range of motion, no swollen or erythematous
joints.
Extremities: DTR: Biceps, triceps, brachioradialis, patellar, and Achilles 2+ B/L. Negative for
edema or cyanosis, no calf tenderness
Peripheral Vascular: Pulses: Carotid 3+ b/l, radial 3+ b/l, posterior tibial 2+ b/l, and dorsalis
pedis 2+ b/l
Lymphatic: No enlarged or tender nodes found in the anterior/posterior cervical, clavicular, or
trochlear chains
Neurological: Patient awake, alert, and oriented, no focal deficient detected.
Labs
1. EKG showed diffuse ST elevation
2. Chest x-ray: small right lower lobe pleural effusion
3. Chest CT: worsening metastatic disease in right middle and lower lobes
Assessment:
1.
Worsening metastatic disease
2.
Pneumonia (bacterial, viral, or fungal)
3.
Myocardial Infarction
4.
Metastatic Pericarditis
5.
Pulmonary Embolism
6.
Lobar Atelectasis
7.
Pain related to chemotherapy and radiation
8.
Angina
Plan:
1.
2.
3.
4.
5.
6.
7.
8.
Admit the patient to the medical floor.
Consult hematology/oncology and infectious disease.
Stat Echo
Continue all home meds
Check cardiac enzymes x 3
Check CBC, CMP
Begin Prednisone 20mg PO TID
Monitor glucose morning, evening and with each meal
Christie E. Slottje, PA-S
Christie E. Slottje, PA-S
3/27/2013 3:15 pm