please this is my last chance to resubmit this assignment. please pay attention to the comment below ------this assignment is a Mental health comprehensive assessment -----your HPI needs more comprehe

History and Physical

Date:

Chief Complaint: “I am having some trouble catching my breath here lately and my chest is hurting”

History of Present Illness: This 94-year-old white female with past history of CHF and HTN presented to the Emergency Department yesterday with complaints of shortness of breath and chest pain.  She states that these symptoms have been present for the past 3 days then yesterday began having worsening shortness of breath and increasing chest pain located in the central chest, which she describes as “pressure”.  Associated symptom of lower extremity edema.  States no alleviating factors. She states she has attempted rest and elevation on extremities, however has had no long term relief of symptoms. She states the pain was 6-7/10 in intensity at the worse and currently 1/10.   She was admitted to the hospital where cardiac workup has ensued with negative findings with cardiac enzymes and serial troponin tests. Chest x-ray shows no acute infiltrate.

Medications:

1. Crestor 10mg oral every night

2. Flonase 50mcg/inh nasal spray, 2 sprays each nare daily

3. Furosemide 40mg oral BID

4. Micardis 40mg oral daily

5. Potassium Chloride 10mEq oral TID

6. Prilosec 20mg oral daily

7. Relafen 750mg oral daily

8. Xanax 0.5mg oral TID, as needed

9. Zaroxolyn 2.5mg oral daily

10. Zoloft 50mg oral daily

11. Zyrtec 10mg oral daily

12. Amlodipine 5mg oral daily

13. Aspirin 81mg oral daily

Allergies:

1. Celebrex – upset stomach

2. Morphine – oversedation

3. Tetanus Toxoid – Rash

Past Medical History:

1. Congestive Heart Failure – Controlled until recent issue

2. Hypertension – Controlled

3. Dyslipidemia – Controlled

4. Anxiety Disorder - Controlled

5. Depression – Controlled

6. Diverticulitis – Controlled

7. Seasonal Allergies – Controlled

8. Osteoarthritis – Controlled

9. GERD – Controlled

Past Surgical History:

1. Colectomy 1992 (Diverticulitis)

2. Appendectomy 1992

3. Bilateral Knee Replacement 1995, 1996

4. Hysterectomy 1984

Sexual/Reproductive History:

Heterosexual, widowed, elderly female who denies sexual activity for “many years” since her husband’s death. She has 3 living children and 2 deceased children. Post-menopausal, hysterectomy 1984

Personal/Social History:

Denies ever smoking, denies alcohol or illicit drug use.

Immunization History:

Her immunizations are not up to date regarding tetanus due to allergy to vaccine.  She has received an influenza vaccine this year and states received a pneumonia vaccine last year from her PCP.

Significant Family History:

Father passed away at age 62 from colon cancer. Brother also passed away from colon cancer at age 74.  She has no other siblings and her mother died of natural causes.  She has a daughter with a significant history of heart disease.

Lifestyle:

Patient lives with her daughter and is very independent with activities of daily living. She has been widowed for 23 years and just was living alone until last year when she chose to move in with her daughter instead of enter assisted living housing.  Her daughter provides her transportation for social events, doctor appointments, and to church activities.  She has a primary care physician she visits regularly, however has never been referred to a cardiologist.  She states that her husband left her a comfortable living when he passed away and she has no financial issues with affording her basic necessities or her medications. She also has insurance coverage through her late husband and Medicare coverage.  She states that she enjoys attending a weekly ladies meeting at her church in which different activities are scheduled each week such as quilting, canning, and volunteer work for the needy in the community. 

Review of Systems:

General: + fatigue, no fever, no chills, +weakness, +decreased activity, no significant  weight loss or gains

HEENT: No changes in vision or hearing, +wears glasses, no glaucoma, no diplopia, no blurred vision, +bilateral cataracts (last exam 2 months ago), no ear pain, no drainage, no tinnitus, no epitaxis, +allergic rhinitis (mild seasonal) no mouth lesion, no difficulty swallowing, +edentulous (has dentures that are well fitting), no difficulty chewing

            Neck: No pain, no injury, +limited ROM

            Breasts: No lesions, no color changes, no history of masses or surgeries

            Respiratory: No cough, +SOB at rest, no hemoptysis, +orthopnea, +chest discomfort

CV: +chest discomfort, no palpitations, no syncope, +peripheral edema, no claudication, + history of murmur, no history of arrhythmias, last cardiac workup 1 year ago.

GI: no abdominal pain, no indigestion, no nausea, no vomiting, no diarrhea, +occasional constipation

GU: no change in urinary pattern, +nocturia, +stress incontinence, no history of STD, previous hysterectomy, not sexually active since the death of her husband

            MS: +osteoarthritis, +joint pain, +limited ROM, hx bilateral knee replacements,

Psych: +anxiety, +depression, no sleep disturbance, no confusion, no dementia, no delusions, denies suicidal ideation

Neuro: no syncopal episodes, no headaches, no dizziness, no paresthesia, no change in memory, no changes in gait pattern (walks with assistive device for safety), no seizure history

Integument/Heme/Lymph: no rashes, no lesions, no bruising, no history of skin cancer, no bleeding disorders, no clotting disorders, +history of transfusions with surgery

            Endocrine: no endocrine symptoms or hormone therapies

            Allergic/Immunological: +allergic rhinitis (seasonal), no known immune diseases

OBJECTIVE DATA

Physical Exam:

Vital Signs: B/P 111/71, left arm, sitting; Pulse 88 and regular; Resp 28 slightly labored; Pulse Ox 98% on Room Air; Temp 98.7 orally; Wt: 128lbs; Ht: 5’4”; BMI 22

General: Well-groomed elderly female who is alert, oriented X3, appears mildly nervous/uncomfortable.

Skin: No rash or open wounds, warm and dry with pink color. Nail beds pink with less than 3 seconds capillary refill.

HEENT: PERRLA, normocephalic, moist, pink mucosa, anicteric sclera, pink gums and tongue, slightly pale conjunctiva

Chest/Lungs: Bibasilar crackles, no use of accessory muscles, trachea midline, chest expansion is symmetrical, respirations shallow and slightly labored with talking.

Cardiac/Peripheral Vascular: Regular rate and rhythm, S1, S2, S3 all muffled by Grade 4/6 pansystolic murmur, no rub or gallop, trace pitting edema in bilateral pedals, pulses +3 all extremities, no carotid bruits, no JVD

Abdominal: Non-distended, bowel sounds + x 4 quadrants, no organomegaly, no tenderness, soft

GU: Deferred

Musculoskeletal: Slight reduced ROM in neck and large joints due to osteoarthritic changes, muscle tone and bulk are adequate

Neuro: Cognition intact, answers all questions appropriately, memory is good, oriented to situation, no syncope, no seizures, Cranial nerves grossly intact, DTR’s intact

Assessment:

Acute Diagnosis:

1.     Shortness of Breath-Differential Diagnosis

1. Congestive Heart Failure Exacerbation – Patient has established past medical history of CHF along with bibasilar crackles, shortness of breath, and edema in lower extremities consistent with signs and symptoms of  heart failure (Kusumoto, 2012). 

2. Mitral Regurgitation – Patient has pansystolic grade 4 murmur with a muffled third heart sound.  Elevation in pulmonary capillary pressure leads to the onset of pulmonary edema which is manifested by shortness of breath (Kusumoto, 2012). 

3. Aortic Regurgitation: Presence of a systolic murmur along with the symptoms of pulmonary edema indicate aortic regurgitation may be implicated in the cause of shortness of breath (Kusumoto, 2012). 
    

2.     Chest Pressure/Pain – Differential Diagnosis

1. Congestive Heart Failure Exacerbation – Patient has established history of CHF along with current signs and symptoms such as bibasilar crackles, chest pressure, shortness of breath, and peripheral edema consistent with diastolic dysfunction. Chest discomfort could be attributed to volume overload and additional respiratory workload (Kusumoto, 2012).

2. Coronary Artery Disease – Acute myocardial infarction has been ruled out with serial cardiac enzymes negative, however may have aortic stenosis which could contribute to chest discomfort along with other symptoms of dyspnea and fatigue (Kusumoto, 2012). 

3. Anxiety – Patient has longstanding history of anxiety and depressive disorder in which she takes medication for.  Symptoms of anxiety include both chest pain and dyspnea  (Kupper, Bonhof, Westerhuis, Widdershoven, & Denollet, 2016).

Established Diagnosis:

1. Congestive Heart Failure – possibly decompensated on current treatment regimens

2. Hypertension – controlled with current medications

3. Dyslipidemia – controlled with medication

4. Anxiety/Depression – possibly contributing factor to current signs and symptoms, will need further evaluation

5. Seasonal Allergies – Controlled on current medications

6. Osteoarthritis – Controlled with current medications

7. GERD – Controlled with current medications