Comprehensive: HTN, Rash
HR is an 85 y.o. Cauc. Woman, widowed since 1969, lives alone in a
Sr. high-rise apartment. She has one daughter that lives close by.
Source of the history is from the patient and also her daughter.
Patient other than being unable to remember some of the dates PMH is
a reliable historian.
CC: Patient presents with two health concerns
1. HTN. Patient states that she has her BP checked biweekly and her
pressures have been in the range 150-170s systolic and 70-80
diastolic over the past two months. She denies being symptomatic, no
c/os of headaches, blurred vision, or dizziness. She has a hx of HTN
for approx. 15 years and has been medically managed. She is
concerned since her systolic BP is higher than what her blood
pressures have been in the past, they usually are anywhere from 130160 systolic.
2. Rash. Patient developed a rash yesterday, which she attributes to
an increase in anxiety due to a stressful visit with person she met for
lunch. Rash is localized to her anterior neck. Denies itchiness or pain.
No change in soap, detergent, lotions or makeup. States she has had
a history of rashes in the past related to her stress. She says she does
have a hydrocortisone cream which she applies twice a day and has
helped in the past.
PMH:
General state of health. States that she has been fairly healthy.
Childhood illnesses. Chicken pox, mumps.
Adult illnesses. Hypertension 1980 and on.
Accidents and injuries. Right humerus fracture in 1992.
Surgeries. Bilateral cataracts 1992 and 1993. Cystoscopy 1980.
Hemerrhoidectomy approximately 30 years ago. Colon Polypectomy
1989.
Hospitalizations. Hyponatrimia and right arm fracture secondary to fall
1994. Above surgeries. Childbirth x2.
Psychiatric illnesses. Depression and anxiety diagnosed June 1994.
Current Health Status:
Allergies. None known.
Immunizations. Pneumovaccine 1994. Flu shot 10-95. Unable to
remember last tetanus.
Screening tests. Ophthalmologist annually, dentist annually,
audiologist every three months. Pap last two years ago. Mammogram
10/1994.
Safety. Uses cane when she goes out, wears seatbelt.
Exercise. Three times a week goes to exercise class in her building,
walks halls every day, does pulley exercises every day.
Sleep. Goes to bed at 9 p.m. Wakes at 7 a.m. No difficulty sleeping.
Diet. Watches her cholesterol, otherwise regular diet.
Current medications. Paxil 20mg QD, Ativan 0.5mg tid, Tenormin
25mg QD, Norvasc 5mg QD, aspirin 1 QD, colace 1 QD, calcium 1 QD,
multivitamin QD.
Tobacco. None, no history.
Alcohol and illicit drugs. None.
Family History
Both parents died of heart disease, father at age 69, mother at age
72. One sibling brother died of lung cancer at age 68.
Psychosocial History
HR is a widow fro twenty-five years, retired a year and a half ago.
She was a teacher. Moved a year and a half ago to live closer to her
daughter. Socializes with many residents in her senior based high
rise.
Review of Systems
General. Weight stable 108 lbs. States she has been healthy the past
year.
Skin. Rash see CC #2, has thickened great toenail beds and also left
thumb.
Head. Denies H/As.
Eyes. Wears glasses for reading otherwise sees without any difficulty.
No problems with night vision, no floaters, no double vision, no visual
changes.
Ears. Bilateral hearing aids in, able to hear well with hearing aids.
Denies tinnitus, vertigo, earaches, or drainage.
Nose. Denies runny nose or sinus pressure. Had a bloody nose one
month ago, which she attributed to the dry air, uses a humidifier now
and has had no further, bloody noses.
Mouth and throat. Full upper and lower dentures. No sore or bleeding
gums, no mouth lesions. No history of frequent sore throats. No
difficulty with swallowing or problems with eating particular foods.
Neck. Denies any swollen lymph nodes, goiter, pain or problems with
her neck.
Breasts. No masses, lumps or discharge from nipples. States does
monthly breast exams.
Respiratory. No SOB, PND, or difficulty breathing. Denies cough.
Denies any hx of respiratory diseases.
Cardiac. No C.P., tightness, or pressure. No palpitations or skipped
heart beats.
GI. Bowels regular Qd. No diarrhea or constipation. No bloody or
black, tarry stools. Denies abdominal pain, heartburn, or indigestion.
No weight loss or change in appetite.
GU. No frequency, burning or discomfort on urination. No hematuria.
Occ. Nocturia 1x noc. No hx UTIs. No problems with dribbling or
incontinence.
Genital. No vaginal discharge or itching. Not sexually active since
death of spouse.
Peripheral vascular. Denies leg cramps or leg pain. Has a few
varicosities legs bil.
Musculoskeletal. Denies joint aches or pains, denies arthritic
symptoms. Uses cane when she goes out to help her with balance
getting up and down curbs.
Neurologic. No numbness or tingling. No hx seizures, stroke, dizzy
spells or fainting.
Hematologic. Denies easy bruising or bleeding. No hx anemia.
Endocrine. Denies heat or cold intolerance. Denies polydypsia,
polyuria or hx diabetes,
Psychiatric. States that she is being treated for depression and
anxiety. Relates depression to moving here, leaving established
friends and work, which she greatly enjoyed, was very difficult for her.
She moved here to be closer to daughter. She had increasing health
problems and needed the support and help of her daughter, so she
thought it best to move. States her daughter confirms that she
internalizes her stress and tends to worry about things, the Ativan
helps her to relax, not to get things out of proportion and obsessively
worry.
Physical Exam
General. Slender, well-groomed elderly woman looks stated age.
Vitals. Initial BP 178/80, half an hour later 153/70, R 20, HR 84.
Height 5’2” Weight 108.
Skin. Fair skin, hair fine, thinning on crown, auburn-colored.
Erythematous popular rash on lateral and anterior base of neck. No
other rashes present on body.
Eyes. PEARRLA. Extraocular movements all fields. Red reflex
present, optic discs creamy white, well defined. Lower lids sagging
tissue bil. R > L.
Ears. Auricles intact. Canals with cerumen. TM intact, bony
landmarks visualized. Bil. hearing aids.
Nose. Membranes moist, no polyps seen, septum midline. No frontal
or maxillary tenderness.
Mouth. Full upper and lower dentures. Gums and tongue pink without
sores or erythema. Mucosa pink, intact, without lesions.
Neck. See above re: rash. Trachea midline. Thyroid normal size,
without nodules.
Lymph nodes. No enlarged nodes.
Resp. Respirations even, unlabored. Thorax symmetrical. Lungs
clear.
Cardiovascular. No JVD. Carotids without bruits. PMI at apex, no
thrills or heaves. Heart tones regular, S1 S2, soft murmur at apex
grade II/VI.
Breasts. Symmetrical, no masses, no dimpling or nipple discharge, or
tenderness.
Abdomen. Flat, soft, no scars. Bowel sounds X4. No tenderness, no
masses. No abd. Bruit. No hepatosplenomegaly.
Genital. Vulva atrophic, without lesions. Vaginal vault pale pink, no
lesions or discharge, cervical os slit-like, also without lesions. Adnexa
nl, uterus small, smooth. Recto vaginal exam nl, no masses.
Hemmocult negative stool.
Peripheral vascular. Small varicosities lower extremities. No
peripheral edema. Dorsalis pedis, posterior tibial 1+, and radial pulses
2+, no femoral bruits.
Musculoskeletal. Gait small steps although not a shuffle. Extremities
full ROM.
Neurological. Sensory function and cranial nerves II-XII intact.
Negative Babinski and Romberg. Patellar reflexes brisk, other reflexes
1+, all were symmetrical. Sensation extremities intact.
Mental status. Alert and oriented woman.