Preceptorship Write-up # 5

CC: L.S. is a 62-year-old African American woman who came in 3 days ago with shortness of
breath that lasted an hour.

HPI: L.S. has a history of COPD, heart failure and hypertension. She has experienced this same
shortness of breath in the past. Her first episode occurred on December 2014, when she inhaled
smoke from a fire. Her second episode occurred on September 9 th 2015. The third episode
occurred on October 29th of 2015. During each exacerbation, L.S. was intubated at Coney Island
Hospital. Her most recent episode happened while she was eating dinner (grilled chicken,
macaroni and cheese) 3 days ago. Concurrently, the patient checked her blood pressure, which
was 216/101. She took aspirin, but it did not alleviate her SOB. She called the ambulance and
was brought to Coney Island Hospital, where she was subsequently intubated for ventilation.
L.S. had no complaints of chest pain associated with the shortness of breath, however she did
state that her heart was racing. In addition, she stated having wheezes and chills. The patient
has not smoked since 1998, but before then has had a 28-pack year history of smoking. The
patient also has a history significant of diabetes type II and high cholesterol.

PMH:
1. Sarcoidosis Diagnosed in the 1980s by neck and liver biopsy. No medications currently
taken.
2. Breast cancer Diagnosed in 1999. Both breasts and axillary lymph nodes on right side were
removed. No recurrence of the cancer.
3. Diabetes Type II Diagnosed in 2005. Managed with insulin (Lispro) and Sitagliptin (Januvia).
4. Hypercholesterolemia Diagnosed in 2005. Managed with simvastatin.
5. Hypertension Diagnosed in 2010. Poorly controlled. Managed with Labetalol (TRANDATE),
and furosemide (Lasix).
6. Acid reflux Diagnosed in 2010. No medications currently taken.
7. Asthma/COPD Diagnosed on September 2015. Managed with Montelukast sodium.
8. Heart failure Diagnosed on October 29th 2015. Managed with Heparin sodium, and aspirin.

Hospitalizations:
Hospitalized for lobular pneumonia bilaterally on October 29th 2015.

Past Surgical History:

Breast and right axillary lymph node removal in 1999.

Medications:

Labetalol (TRANDATE) 300 mg PO daily

Montelukast sodium 10 mg PO daily
Heparin sodium 5000 units SubQ q8 hours
Insulin (Lispro) Sliding scale
Sitagliptin (Januvia) 100 mg PO daily
Furosemide (Lasix) 20 mg PO daily
Simvastatin 20 mg PO daily
Aspirin 81 mg EC tab PO daily

Immunizations: All up to date.

Allergies: Red delicious apples (gives her hives) and erythromycin

Family History: The mother passed away of lung cancer in 2011 at age 73. Her mother also had
diabetes and hypertension. L.S. has no recall of father (she does not remember meeting him).
She has no siblings. She has 2 sons, ages 35 and 38 years old. Both sons are healthy, however the
35 year old son has hypertension.

Social history: L.S. was born in North Carolina. She lives in an apartment in Brooklyn with her
sons and 2 cats. She has a boyfriend. Has good relationship with family. She eats relatively
healthy: grilled chicken, fish, salad, occasional macaroni and cheese. She stays hydrated and eats
fresh vegetables. She used to provide care for mentally unstable adults and has been retired since
December 18th, 2014. She has not drunk alcohol or smoked since 1998. She has also stopped
smoking marijuana since 1998. She enjoys walking. She is a monogamous relationship with her
boyfriend. She hasnt had sex in awhile but when she did, she always used condoms.

Review of Systems
General No fever, nightsweats, weight loss or gain, heat or cold intolerance
Eyes No changes in vision, no blurry vision, no vision loss, no diplopia, no eye pain, no
photophobia, no redness of eyes, no tearing
Ears No difficulty hearing, no tinnitus
Nose No nose bleeds, no runny or congested nose,
Mouth No bleeding gums, no sores in mouth, no sore throat or hoarseness of breath
Pulmonary Shortness of breath episodes with wheezing. No sputum, no hemoptysis
Cardiac Has palpitations, no chest pain/pressure, no dyspnea on exertion, no orthopnea, no
syncope, no leg pain while walking
GI Has heartburn, no constipation, diarrhea or vomiting. No nausea, no change in appetite. No
abdominal pain. No hematochezia or melena. No pain or difficulty swallowing.
GU No urgency or frequency. No dysuria or nocturia and no incontinence. No hematuria and
no flank pain.
Endocrine No polydipsia or polyuria. No heat or cold intolerance.
Musculoskeletal No muscle weakness or stiffness, no back pain or joint swelling.
Skin No lumps or masses. No rash or pruritus. No bruising or bleeding.
Neurologic No focal weakness or paralysis, no vertigo, no loss of sensation, no gait
disturbance, no loss of coordination.
Psychiatric Patient is happy with no change in sleep or appetite. No panic attacks, no anxiety

Physical Exam:

Vital signs BP 154/93, RR 15, PULSE 92 regular

General An obese African American woman who is no apparent distress laying on the hospital
bed.

HEENT Pupils are reactive to light bilaterally (CN 2 and 3). Extraocular movements are all
intact (CN 3, 4 and 6). No deviation uvula, no deviation of tongue when protruded (CN 10 and
12 respectively). Nose is patent, no erythema. Ears are clear of debris and nontender. Tympanic
membrane is clear, with no rupture.

Neck Jugular venous distention is present while patient is lying 45 degrees upright. No
masses, or tumors. Trachea is midline. No carotid bruits.

Respiratory Some crackles present bilaterally. Lungs are dull to percussion near lung base,
bilaterally.

Cardiac The point of maximal impulse is in the 5th intercostal space at the midclavicular line.
Normal S1 and S2. Possibly an S3. Pitting edema present on legs bilaterally. No murmurs, no
gallops.

GI Normal bowel sounds, abdomen is soft and not tender. There are no masses and no
hepatosplenomegaly.

Extremities There is no cyanosis present on all patients extremities. Dorsalis pedis pulse is
strong, posterior tibialis pulse is strong. Negative Homans sign.

Skin Some nevi are present on patients back. No petechiae or ecchymoses. No rashes or
scaling. Skin has good turgor.

Neurological Patient is awake, alert and receptive to questions being asked. Patient is oriented
to person, place and time. Patient has normal dull and sharp sensation on face bilaterally (CN 5).
Patient has strong bite and normal jaw motion (CN 5). Facial expression is intact: patient is able
to close eyes against resistance and show teeth (CN 7). Hearing is also intact (CN 8). Patient is
able to shrug shoulders against resistance (CN 11). Patient has good muscle tone in upper and
lower extremities for both extensors and flexors bilaterally. Patient has normal light touch and
vibration sense bilaterally. Patient has normal finger to nose test to check for cerebellar function.

Musculoskeletal Patient has no observable joint deformity. Joints are not swollen or warm to
touch.