IM: History and Physicals

History and Physical 1

Amber Shaikh

H&P 1

Identifying data:

Full Name: AD

Sex: M

Address: Hicksville, NY

Age: 48 Y/O

Date & Time: 06/28/21 9:00am

Location: NSUH

Religion: Denies

Marital Status: Married

Race: Caucasian

Nationality: American

Source of Information: Self and family

Reliability: Reliable

Mode of Transport: Self

Chief Complaint: “I passed out earlier today”

History of Present Illness:

AD is a 48 year old male with a past medical history significant for HTN, HLD, hypothyroidism, Diabetes Type 2 on Glipizide, Renal call carcinoma status post right nephrectomy in 2016 currently on prednisone, and irregular heart beats, who presents after having a syncopal episode earlier today. Patient states that was at a BBQ party earlier today when he started feeling sweaty, lightheaded and unlike himself. He says that he went to lay down on the couch to rest since he was feeling unwell, and the next thing he remember is seeing EMS surrounding him. His daughter, who is also at bedside and who was there during the event today states that soon after he laid down on the couch, he passed out and she was unable to wake him up. She states that he had loss of consciousness for about 3-4 minutes. He denies hit his head or falling. As per the EMS report, his finger stick at the time of the event was 51. Patient was then taken to the ED, where he continued to feel diaphoretic and lightheaded. His finger stick was repeated in the ED and was 36. The patient stated that walking and activity exacerbated his symptoms and rest alleviated them. In the ER the patient rated his lightheadedness a 6/10 and said that it comes in waves. He says that he is usually very compliant with the dose of his Glipizide medication, but is unsure if he took 2 tablets instead of one this morning. The patient endorses having lightheadedness, increased sweating, dizziness and fatigue. Otherwise, he denies any fever, chills, cough, shortness of breath, nausea, vomiting or diarrhea. He also denies having any chest pain, palpitations or radiating arm or jaw pain prior to the syncopal episode. Patient states that he has never had similar symptoms in the past.

In the Emergency Room, the patient was given 1 liter of Dextrose 5% Normal Saline fluid and Octreotide. His repeat finger stick soon after starting treatment was 128. He denies any complaints at this time.

Past medical history:

DM2 (diabetes mellitus, type 2): Diagnosed in 2011, controlled with medication
HLD (hyperlipidemia): Diagnosed in 2009, controlled with medication
HTN: Diagnosed in 2009, controlled with medication

Hypothyroidism: Diagnosed in 2013, controlled with medication
Renal cell cancer: Diagnosed in 2015; patient had a R sided nephrectomy

Present illnesses: syncope and lightheadedness

Hospitalizations: patient has had several hospitalizations due to his renal cell carcinoma, but is unsure of exact dates.

Immunization: patient is up to date on immunizations

Flu shot: Dec 2020
COVID vaccine: Pfizer Apiril 2021

Screenings:

Patient is up to date on his depression and HTN screening (Dec 2020) . As per his PCP, no other screenings are required at this time.

Past surgical history:

Lasix surgery in 2013: done at Northwell LIJ, with no complications
Right nephrectomy in 2016: done at NSUH, with no complications

Medications:

Amlodipine Besylate 10mg 1 tablet PO QD – last dose taken this morning

For HTN

Atorvastatin 40mg 1 tablet PO QD- last dose taken this morning

For HLD

Carvedilol 25 mg 1 tablet PO BID- last dose taken this morning

For HTN

Glipizide 10mg 1 tablet PO BID- last dose taken this morning

For diabetes

Hydroxyine Pam 50 mg capsule, 1 cap every 6 hours PRN- last dose taken was 1 week ago

For seasonal allergies as needed

Levothyroxine 200 MCG 1 tablet PO QHS: last taken last night

For hypothyroidism

Losartan potassium 50 mg 1 tablet PO QD: last taken this morning

For HTN

Prednisone 10 mg 3 tablets daily QD (taper dose): last taken yesterday

For renal cell carcinoma, post surgery treatment

Aspirin enteric coated 81mg oral delayed release tablet QD: last taken this morning

For anticoagulation

Allegra 180mg tablet QD: last taken yesterday

For seasonal allergies

Multivitamins oral tablet: last taken yesterday

Allergies:

Seasonal allergies to pollen and dust
Denies any allergies to medications or food

Family history:

Mother: HTN diagnosed at 43, controlled with medications. Alive and well
Father: Lung cancer diagnosed at 56, treated. Alive and well

Social history:

Habits:

AD denies ever smoking, drinking alcohol or using any illicit drugs

Travel:

Patients denies any recent travel

Marital history:

Patient is currently married to his wife for 15 years.

Occupational history:

Patient works at a grocery store

Sexual history:

AD is sexually active with his wife, and us condoms as contraceptive. He denies any history of being tested for any STDs

Home:

He lives in a private home

Diet:

Patient eats a healthy balanced diet or chicken and vegetables

Exercise:

AD exercises 2-3 days a week, and is very active daily

Sleep:

Patient gets 7 hours of sleep a night

Safety:

Patient adheres to all safety practices.

Review of Systems:

Constitutional: admits to fatigue and diaphoresis, but denies any headache, fever, loss of appetite, weight changes, or night sweats

Skin, hair, nails: Admits to increased sweating. denies changes in skin and hair texture. No lesions, or dryness. No discoloration, pigmentation, moles or rashes

Head: admits to lightheadedness and dizziness, denies any vertigo, or head trauma, fracture or coma

Eyes: patient does not wear glasses, last eye exam was over 5 years ago-normal. Denies any visual changes, double vision, photophobia, noncitric, or pruritis

Ears: denies decreased hearing, tinnitus, pain, lesions, discharge or use of hearing aids

Nose/sinuses: denies any discharge, epistaxis, or obstruction

Oropharynx: denies any lesions or ulcers, denies bleeding gums, dentures, erythema, tongue lesions, tonsillar exudate. Uvula midline. No changes in teeth. Last dental exam was 3 years ago-normal

Neck: neck is supple and nontender. He denies localized adenopathy or swelling. FROM. Thyroid midline

Breast: denies lumps, pain or nipple discharge

Pulmonary: denies dyspnea, shortness of breath, wheezing, orthopnea, cyanosis, hemoptysis, cough, accessory muscle use or paroxysmal nocturnal dyspnea.

Cardiovascular: Admits to diaphoresis and syncope. He denies any chest pain, palpitations, pedal edema, or known heart murmur.

Gastrointestinal: Denies any abdominal pain, constipation, nausea, vomiting or diarrhea. Denies any changes to flatulence, eructation or acid reflux. Denies any melena or hematemesis.

Sexual history: as mentioned above

Genitourinary history: denies dribbling, incomplete urination, frequency, dysuria, or urgency. Denies oliguria, nocturia, polyuria or flank pain

Nervous: Admits to loss of consciousness, denies seizures, sensory changes, motor loss, ataxia, loss of strength, change in cognition or memory

MSK: denies myalgias, swelling, redness, warmth, arthritis, or any joint or muscle pain.

PVS: denies coldness r trophic changes. No color changes or cyanosis. Denies peripheral edema or varicose veins. No intermittent claudication

Heme: denies bleeding or bruising easily, denies anemia or lymph enlargement. No history of DVT/PE

Endo: Admits to increased sweating, but denies polyuria, polydipsia, polyphagia, heat or cold intolerance, goiter or hirsutism.

Psych: denies depression, anxiety, psychosis, OCD or ever seeing a psychiatrist.

Physical Exam:

Vitals:

Temp: 97.8F orally, BP: 157/90 (right arm, supine), HR: 58 regular, Resp rate: 18 nonlabored, SpO2: 99% on room air, Height: 69iches, Weight: 165lbs, BMI: 24.2

General: good lightening and draping. Patient was alert and oriented x 3 to person, place and time. Patient had good hygiene, and looked appropriate age. Patient is not in any acute distress.

Skin, hair and nails: warm, moist texture, good turgor, noncitric, no rashes, lesions, scars, masses, thickness or opacities. Nails are normal shape with cap refill of less then 2 seconds on fingers and toes. No spooning, clubbing, or paronychia noted. Hair has good texture and is evenly dispersed. No lice or seborrhea noted.

Head: normocephalic, atraumatic. No lesions or masses. No pain or tenderness in any of the lobes. No facies or deformities noted.

Eyes: Sclera is white and conjunctiva is clear. OU Symmetrical. Normal hair distribution of lashes and eyebrows. No eyelid lesions, discharge or swelling. Lacrimal glans without excess tearing, dryness or erythema. No strabismus, ptosis, or exophthalmos. Visual acuity is 20/20 OS, 20/20 OD, 20/20 OU (no glasses). Visual fields full OU. EOMI, no nystagmus, PERRLA. On fundoscopy, red reflex visible with a cup to disc ratio OU of <.5. No cotton wool spots, neovascularization, AV nicking, hemorrhages or exudates.

Ears: Symmetrical no lesions, masses or trauma on external ears. No discharge or foreign bodies in external auditory canals AU. Tympanic membrane is pearly white and intact with cone of light in appropriate position AU. Auditory acuity intact to whispered voice bilaterally. Weber midline/Rinne reveals AC>BC AU.

Nose: Symmetrical, no masses lesions or deformities, trauma or discharge. Nares patent bilaterally, nasal mucosa pink & well hydrated. No discharge noted on anterior rhinoscopy. Septum midline without lesions, deformities, injection or perforation. No foreign bodies.

Sinuses: frontal and maxillary sinuses are nontender to percussion. Transillumination is unremarkable

Oropharynx: pink, well hydrated, no tonsillar enlargement or exudates. Uvula is pink and midline. No lesions

Lips : Pink, moist no fissures; no cyanosis or lesions. Non-tender to palpation.

Mucosa : Pink; well hydrated. No masses. Lesions or ulcers. Non-tender to palpation. No signs of leukoplakia.

Palate: Pink, well hydrated. Palate is intact with no lesions; masses, and continuous; scars. Non-tender to palpation

Teeth: Good dentition and no obvious dental caries or deformities noted.

Gingivae: Pink; moist. No hyperplasia, lesions, masses or erythema. Non tender

Tongue : Pink; well papillated throughout; no masses, lesions or deviation noted. Non-tender

Neck: Supple, nontender. Trachea midline. No stridor, thrills or bruit noted. Carotid pulse 2+ bilat. No masses; lesions; scars; pulsations noted. With FROM, and no adenopathy noted

Thyroid: Midline, non tender, with no palpable masses or bruit.

Thorax & Lungs

Chest: Symmetrical with no masses, lesions, or deformities. No signs of trauma. No use of accessory muscles, respirations are unlabored. Lat to AP diameter is 2:1. No tenderness to palpation

Lungs: Symmetrical breath sounds noted bilaterally, clear to auscultation and percussion. Tactile fremitus throughout, without any adventiscious sounds. Clear to auscultation and percussion bilaterally. Chest expansion and diaphragmatic excursion symmetrical.

Cardiac: regular rate and rhythm, s! And S2 intact with no murmurs. No S3, and S4, no rubs or gallops. JVP is 3 cm above sternal angle with bed at 30 degrees. PMI is 5th ICS midclavicular line. Carotid pulses 2+ bilaterally, no bruits.

Abdomen: flat, nondistended, symmetric with no masses, lesions. Surgical scar from right nephrectomy is healing well. No pulsations. Bower sounds are normoactive, with no bruits. Non tender to palpation, and abdomen is tympanic throughout. No hepatosplenomegaly. No CVA tenderness.

MSK: no ecchymosis, edema, erythema, bleeding or deformities. Non tender. FROM to upper and lower extremities. Strength is 5/5 in UE and LE. Negative meningeal signs

GU and Rectal: patient denies exam, non-contributory to this presentation. However if we were to do it, would check for any lesions or ulcerations or discharge. Check for any hernias, outpouchings or tenderness. In rectal exam, would check for stool color, rectal tone and would palpate the prostate.

PVS: extremities are noncyanotic, no varicosities, unremarkable size and temperature. PT and DP pulses are 2+. No pitting edema.

Neuro: mental status: A&O x 3 to person, place and time. No dysphonia, dysarthria or aphasia. No slurring of speech or face drooping. CN 2-12 are intact. Normal cerebellar function. No gait abnormalities. 5/5 motor strength in LE and UE, 5/5 sensations to UE and LE. Sensations intact to light, sharp and dull touch.

Psych: patient does not appear to be in an psychiatric distress, no signs of depression, anxiety or psychosis present.

Labs and results:

Hematology:

13.7

11.02 )———–( 264

40.9

Chemistries:

134<L> | 98 | BUN70<H>

—————————-< Gl 152<H>

3.8 | 21<L> | Cr 2.43<H>

Ca 8.7

TPro 6.2 / Alb 3.7 / TBili 0.4 / DBili x / AST 25 / ALT 37 / AlkPhos 51

LIVER FUNCTIONS:

Alb: 3.7 g/dL / Pro: 6.2 g/dL / ALK PHOS: 51 U/L / ALT: 37 U/L / AST: 25 U/L / GGT: x

CAPILLARY BLOOD GLUCOSE:

POCT Blood Glucose.: 70 mg/dL (28 Jun 2021 00:10)

POCT Blood Glucose.: 128 mg/dL (27 Jun 2021 22:57)

POCT Blood Glucose.: 210 mg/dL (27 Jun 2021 20:52)

POCT Blood Glucose.: 36 mg/dL (27 Jun 2021 20:31)

Imaging:

CXR: impression: clear lungs, with no focal opacities

EKG: impression: Normal sinus rhythm at a heart rate of 75, with no acute ST changes.

Differentials:

Hypoglycemia (secondary to Sulfonylurea)

Hypoglycemia secondary to missing a meal

Valvular disease/arrythmia

Adrenal insufficiency

Assessment:

AD is a 48 year old male with a past medical history of type 2 Diabetes, HTN, HLD, hypothyroidism, renal cell carcinoma s/p nephrectomy on prednisone, and irregular heart beats who presents to the hospital after having a syncopal episode at a party. Patient is unsure if he doubled his dose of glipizide this morning. History, labs, and physical are consistent with hypoglycemia.

Plan:

Hypoglycemia in the setting of sulfonylurea use:

Patient will be admitted to the inpatient floors in order to monitor glucose levels
In the hospital patients finger stick trended from 210–>128–>70
Patient received octreotide 50mcg x 1, will start octreotide gtt at 50mcg/hr while admitted
Start patient on a D5W at 75cc/hr drip
Monitor Finger stick every 1 hour until 3 normal consecutive values

Hold glipizide, until sugar is controlled
Obtain an endocrinology consult in the morning

Diabetes Type 2:

Hold glipizide for now
Blood glucose monitoring every 1 hour for now, followed up by every 4-6 hours

Obtain endocrine consult
Educate patient on correct medication use, possibly adjust dose

Hypothyroidism:

Continue taking Synthroid as prescribed

Renal Cell cancer

Continue prednisone taper
Follow up with outpatient oncology

HLD:

Continue taking atorvastatin as prescribed

HTN:

Continue taking amlodipine, carvedilol and losartan as prescribed
f/u with cardiology

History and Physical 2

Amber Shaikh

H&P 2

Identifying data:

Full Name: MN

Sex: F

Address: Plainview, NY

Age: 44 Y/O

Date & Time: 07/8/21 11:00am

Location: NSUH

Religion: Denies

Marital Status: Married

Race: African American

Nationality: American

Source of Information: Self

Reliability: Reliable

Mode of Transport: Self

Chief Complaint: “I felt short of breath and weak since yesterday”

History of present illness:

MN is a 44 year old African American female with a past medical history significant for Myasthenia Gravis diagnose din 2013 (ACH-R positive, treated with Plex, eculizumab, azathioprine), who is s/p thymectomy in 2015, recurrent pulmonary embolism (3/2015 and 10/2015, on Lovenox) who presents to the ED with complaints of shortness of breath and weakness since yesterday. She is also having associated limb weakness and difficulty swallowing. Patient states that she has experiences symptoms with her MG before, but has never had difficulty breathing to this extent. She says this started when she was resting at home, and has been worsening. The dyspnea is at rest and also worsens with exertion. She reports that “she feels like she couldn’t contract her diaphragm yesterday for 10 minutes.” She reports having worsening weakness in all four limbs, and that her right upper and lower extremities are weaker, which is usual for her MG exacerbations. Patients states that she eats a diet of pureed foods at home, but yesterday was having trouble swallowing that along with water. She says that she usually has drooping of her eyelids, but that it feels weaker today. She denies any changes to vision or hearing. Patient says that she has not been able to give a proper smile in 6-7 months due to facial muscle weakening. Patient reports that she missed her plasmapheresis and eculizumab treatment session yesterday due to a issue with insurance. She says the she undergoes plasmapheresis and eculizumab twice a week, every other week. Per patient, she takes eculizumab Tuesday 1200mg and Thursday 600mg. She also takes azathioprine 100mg daily. She endorses weakness, difficulty swallowing, drooping eyelids and difficulty breathing. She denies any chest pain, fevers, chills, night sweats, nausea, vomiting, or urinary changes.

In the ED, patient has an access port via a MediPort. Her NIF is –40, with a vital capacity o 1070. Her Outpatient Neurologist is Dr. Jones. In the ED, the ICU team was consulted. As per the teams consult, the patient was AxO times 4, to person, place, time and president. She was able to protect her airway, and did not have significant bulbar signs. She is not currently drooling and is able to speak in full sentences. At this time, she is not considered a MICU candidate.

Past medical history:

Endometriosis
Myasthenia gravis diagnosed 8/2013
NSVD (normal spontaneous vaginal delivery) 1998
Pulmonary embolism 3/2015, and 10/2015

Present illnesses: dyspnea and weakness

Hospitalizations:

2013 for MG diagnosis
2015 for thymectomy
3/2015 for PE
10/2015 for PE

Immunization: patient is up to date on immunizations

Flu shot: Nov 2020
COVID vaccine: Pfizer March 2021

Screenings:

Patient is up to date on his depression and HTN screening (Dec 2020) . As per her PCP, no other screenings are required at this time.

Last mammogram was 2020-normal
Last pap smear was 2019-normal

Past surgical history:

laparoscopy 2006-NSUH no complications
Hysterectomy in 2018 at NSUH no complications

Thymectomy in 2015 at NSUH, no complications
Uterine polyp removal in 2017 at NSUH, no complications

Medications:

Lovenox 60 mg/0.6 mL injectable solution: 60 milligram(s) injectable every 12 hours, last used was a day ago

For recurrent PE

CellCept 500 mg oral tablet: 2 tab(s) orally 2 times a day, last used was a day ago

For myasthenia gravis

Eculizumad twice a week every 2 weeks, 1200mg on Tuesday and 600mg Thursday. Last dose was two weeks ago.

For myasthenia gravis

Azathioprine 100mg daily PO QD, last dose was one day ago

For myasthenia gravis

Allergies:

Keflex: Rash, Swelling
Benadryl: Anaphylaxis
Decadron: Anaphylaxis

Venofer: Anaphylaxis
Keflex: Hives
penicillin: Hives
predniSONE: hives
No food allergies notes

Family history:

Father: Diabetes type 1, age 67, alive and well
Mother: history of HTN, age 69, alive and well

Social history:

Habits:

MN denies ever smoking, drinking alcohol or using any illicit drugs

Travel:

Patients denies any recent travel

Marital history:

Patient is currently married to her husband for 11 years.

Occupational history:

Patient does not work currently

Sexual history:

MN is sexually active with her husband. She denies using condoms or contraceptives. Denies any history or being tested for any STDs.

Home:

She lives in a private home

Diet:

Patient eats a healthy balanced diet or chicken and vegetables

Exercise:

MN walks a lot and takes the stairs

Sleep:

Patient gets 7 hours of sleep a night

Safety:

Patient adheres to all safety practices.

Review of Systems:

Constitutional: admits to fatigue and weakness. denies any headache, diaphoresis, fever, loss of appetite, weight changes, or night sweats

Skin, hair, nails: denies changes in skin and hair texture. No lesions, or dryness. No discoloration, pigmentation, moles or rashes

Head: Denies lightheadedness or dizziness, denies any vertigo, or head trauma, fracture or coma

Eyes: positive drooping eyelids, patient does not wear glasses, last eye exam was over 3 years ago-normal. Denies any visual changes, double vision, photophobia, noncitric, or pruritis

Ears: denies decreased hearing, tinnitus, pain, lesions, discharge or use of hearing aids

Nose/sinuses: denies any discharge, epistaxis, or obstruction

Oropharynx: Admits to difficulty swallowing. denies any lesions or ulcers, denies bleeding gums, dentures, erythema, tongue lesions, tonsillar exudate. Uvula midline. No changes in teeth. Last dental exam was 2 years ago-normal

Neck: neck is supple and nontender. He denies localized adenopathy or swelling. FROM. Thyroid midline

Breast: denies lumps, pain or nipple discharge

Pulmonary: Admits to dyspnea and shortness of breath. Denies any wheezing, orthopnea, cyanosis, hemoptysis, cough, accessory muscle use or paroxysmal nocturnal dyspnea.

Cardiovascular: He denies any chest pain, palpitations, pedal edema, or known heart murmur.

Gastrointestinal: Admits to difficulty swallowing. Denies any abdominal pain, constipation, nausea, vomiting or diarrhea. Denies any changes to flatulence, eructation or acid reflux. Denies any melena or hematemesis.

Sexual history: as mentioned above

Genitourinary history: denies incomplete urination, frequency, dysuria, or urgency. Denies oliguria, nocturia, polyuria or flank pain. Denies any vaginal discharge, lesions or pain. LMP was 3 weeks ago-unremarkable

Nervous: Admits to weakness in UE and LE. Denies LOC, denies seizures, sensory changes, ataxia, loss of strength, change in cognition or memory

MSK: Admits to muscle weakness. denies myalgias, swelling, redness, warmth, arthritis, or any joint or muscle pain.

PVS: denies coldness r trophic changes. No color changes or cyanosis. Denies peripheral edema or varicose veins. No intermittent claudication

Heme: Admits to a history of recurrent PEs. denies bleeding or bruising easily, denies anemia or lymph enlargement.

Endo: denies polyuria, polydipsia, polyphagia, heat or cold intolerance, goiter or hirsutism.

Psych: denies depression, anxiety, psychosis, OCD or ever seeing a psychiatrist.

Physical Exam:

Vitals:

Temp: 37C, orally; HR: 60 regular; BP: 101/69 R arm supine, Resp rate: 18 unlabored, SpO2: 98% on room air, Height: 62 inches, Weight: 120, BMI: 21.9

General: good lightening and draping. Patient was alert and oriented x 3 to person, place and time. Patient had good hygiene, and looked appropriate age. Patient is in mild distress.

Skin, hair and nails: Mediport at right chest wall. Skin is warm, moist texture, good turgor, noncitric, no rashes, lesions, scars, masses, thickness or opacities. Nails are normal shape with cap refill of less then 2 seconds on fingers and toes. No spooning, clubbing, or paronychia noted. Hair has good texture and is evenly dispersed. No lice or seborrhea noted.

Head: normocephalic, atraumatic. No lesions or masses. No pain or tenderness in any of the lobes. No facies or deformities noted.

Eyes: Bilateral eye lid ptosis. Eyelid strength bilaterally is 3/5. Sclera is white and conjunctiva is clear. OU Symmetrical. Normal hair distribution of lashes and eyebrows. No eyelid lesions, discharge or swelling. Lacrimal glans without excess tearing, dryness or erythema. No strabismus or exophthalmos. Visual acuity is 20/40 OS, 20/20 OD, 20/30 OU (no glasses). Visual fields full OU. EOMI, no nystagmus, PERRLA. On fundoscopy, red reflex visible with a cup to disc ratio OU of <.5. No cotton wool spots, neovascularization, AV nicking, hemorrhages or exudates.

Sinuses: frontal and maxillary sinuses are nontender to percussion. Transillumination is unremarkable

Oropharynx: pink, well hydrated, no tonsillar enlargement or exudates. Uvula is pink and midline. No lesions

Lips : Pink, moist no fissures; no cyanosis or lesions. Non-tender to palpation.

Mucosa : Difficult to visualize, as patient could not open mouth fully. However, it is pink and well hydrated. No masses. Lesions or ulcers. Non-tender to palpation. No signs of leukoplakia.

Palate: Pink, well hydrated. Palate is intact with no lesions; masses, and continuous; scars. Non-tender to palpation

Teeth: Good dentition and no obvious dental caries or deformities noted.

Gingivae: Pink; moist. No hyperplasia, lesions, masses or erythema. Non tender

Tongue : Pink; well papillated throughout; no masses, lesions or deviation noted. Non-tender

Neck: No obvious bulbar signs such as jaw weakness. Supple, nontender. Trachea midline. No stridor, thrills or bruit noted. Carotid pulse 2+ bilat. No masses; lesions; scars; pulsations noted. With FROM, and no adenopathy noted

Thyroid: Midline, non tender, with no palpable masses or bruit.

Thorax & Lungs

Chest: Symmetrical with no masses, lesions, or deformities. No signs of trauma. No use of accessory muscles, respirations are unlabored. Lat to AP diameter is 2:1. No tenderness to palpation

Cardiac: regular rate and rhythm, s! And S2 intact with no murmurs. No S3, and S4, no rubs or gallops. JVP is 2.5 cm above sternal angle with bed at 30 degrees. PMI is 5th ICS midclavicular line. Carotid pulses 2+ bilaterally, no bruits.

MSK: weakness of UE and LE extremities, worse on right side. Strength is 4/5 throughout. no ecchymosis, edema, erythema, bleeding or deformities. Non tender. FROM to upper and lower extremities.. Negative meningeal signs

GU and Rectal: patient denies exam, non-contributory to this presentation. However if we were to do it, would check for any lesions or ulcerations or discharge. Check for any lesions, tenderness or discharge. In rectal exam, would check for stool color, and assess rectal tone.

PVS: extremities are noncyanotic, no varicosities, unremarkable size and temperature. PT and DP pulses are 2+. No pitting edema.

Neuro: mental status: A&O x 3 to person, place and time. No dysphonia, dysarthria or aphasia. Mild left sided droop and left sided shoulder shrug. No slurring of speech. Has spontaneous movement of all extremities. No pronator drift. Shoulder abduction 4/5 bilaterally. Elbow flexion and extension 4/5 bilaterally. Bilateral hip flexion 4/5. Bilateral knee extension/flexion 4/5. Bilateral plantarflexion 4/5. Reflexes are 2+ and symmetric at the biceps, brachioradialis and knees. Sensory intact throughout to light touch. Coordination; finger to nose and heel to shin intact without dysmetria. Gait deferred.

Cranial Nerves:

II: Visual fields are full to confrontation; Pupils are equal, round, and reactive to light;

III, IV, VI: Extraocular movements are intact without nystagmus. Bilateral ptosis.

V: Facial sensation is intact in the V1-V3 distribution bilaterally.

VII: Face with normal eye closure. Asymmetric smile (primarily left sided weakness).

VIII: Hearing is intact to finger rub.

IX, X: Uvula is midline and soft palate rises symmetrically.

XI: Head turning and shoulder shrug are intact, but bilaterally weak.

XII: Tongue protrudes in the midline.

Psych: patient does not appear to be in an psychiatric distress, no signs of depression, anxiety or psychosis present.

Labs and Results:

Hematology:

10.5

4.03 )———–( 335

34.8

Chemistries:

139 | 101 | 7

—————————-< 134<H>

5.0 | 24 | 0.59

Ca 10.3

TPro 8.8<H> / Alb 5.3<H> / TBili 0.4 / DBili x / AST 59<H> / ALT 19 / AlkPhos 53

Venous Blood Gas:

7.38/48/23/28/31

VBG Lactate: 1.4

LIVER FUNCTIONS

Alb: 5.3 g/dL / Pro: 8.8 g/dL / ALK PHOS: 53 U/L / ALT: 19 U/L / AST: 59 U/L / GGT: x

Radiology:

Xray Chest :

IMPRESSION:

The heart is normal in size. Lungs are clear. No pleural effusion. No pneumothorax. A MediPort is seen on the right and the tip is in the superior vena cava.

Differential Diagnosis:

Myasthenia Crisis
Respiratory infection
Stroke

Insect bite/venom

Assessment:

MN is a 44 year old female with a past medical history of myasthenia gravis who presents to the ED complaining of dyspnea, weakness, and difficulty swallowing. Patient states that she missed her plasmapheresis and eculizumab treatment yesterday. History, labs and physical exam is consistent with a Myasthenia crisis. Case was discussed with patients outpatient neurologist, and the MICU was consulted.

Plan:

Myasthenia Crisis:

-obtain STAT PT, PTT, INR, Fibrinogen, and ionized calcium; as per transfusion protocol

-Transfusion medicine to start plasmapheresis on 7/7, and continue every other day for a total of 5 sessions

-Notify the blood bank, and alert the neurology floor that the patient will be starting plasmapheresis

-start Eculizumab 1200mg after the first plasmapheresis session

-alert the MICU floor that the patient may need urgent intubation if respiratory failure

-NIF, vital capacity and vital signs every 4 hours

-2 Liters of oxygen via Nasal Canula

-Keep patient NOP for now

-Continue with Lovenox 60mg BID for DVT and PE prophylaxis

#CV:

-Obtain ECG now

#GI/GU:

-Pt presents with dysphagia

-maintain NPO at present

-increase diet as tolerated when improved condition (usual diet of pureed foods)

-strict I & O’s – keep even

#ID:

-No issues at present

-obtain surveillance cultures

-COVID-19 ND

#FEN/ENDO/HEME:

-obtain CMP/Mg++/PO–4/CBC w diff/PT/PTT/INR now and q. a.m.

-place on D5LR @75 cc/hr until taking P.O. food/fluids well

History and Physical 3

Amber Shaikh

H&P 3

Identifying data:

Full Name: LK

Sex: F

Address: Manorville, NY

Age: 58 Y/O

Date & Time: 07/12/21 10:00am

Location: NSUH

Religion: Denies

Marital Status: Married

Race: Caucasian

Nationality: Hispanic

Source of Information: Self

Reliability: Reliable

Mode of Transport: Self

Chief Complaint: “left sided abdominal and back pain for 4 days”

History of Present Illness:

LK is a 58 year old female with a past medical history of asthma and chronic back pain, status post a L4-L5 laminectomy in 2015 presents complaining of left sided abdominal and flank pain for 4 days. She states the pain started when she was resting at home, and was not related to anything to ate. Pain started in the center of the abdomen and then radiated to the left side. She says the pain is constant and sharp and stabbing in nature, and gets worse with certain movements. The pain is exacerbated with sitting and standing, however improves with laying down, rest and with Tylenol. Patient says that when she stands, she feels very nauseous, however denies any vomiting. Patient rates the pain a 8/10 at its worst. She denies eating anything unusual, or anything that might have expired. She denies ever having symptoms similar to this in the past. She states that her last normal bowel movement was 1 day ago, and it was non-bloody. The patient endorses left sided abdominal pain, left sided flank pain, and nausea, but denies any vomiting, pain with urination, blood with urination, increased urgency or frequency, diarrhea, constipation, fevers, sensations of heart burn, chills, chest pain, or shortness of breath. Patient also denies any recent travels or sick contacts.

Past medical history:

Asthma
Chronic back pain

Present illnesses: syncope and lightheadedness

Hospitalizations: Patient has been hospitalized for the L4-L5 laminectomy in 2015

Immunization: patient is up to date on immunizations

Flu shot: Nov 2020
COVID vaccine: Moderna March 2021

Screenings:

Patient is up to date on her screenings

Mammogram 2019-normal
Pap smear 2019-normal
Depression and HTN screening

Past surgical history:

L4-L5 laminectomy 2015

Medications:

Ventolin HFA CFC free 90 mcg/inh inhalation aerosol: Last Dose Taken: 1 week ago

Dose: 2 puff(s) inhaled 4 times a day

For asthma

Tylenol 325mg PRN for back pain

Allergies:

Seasonal allergies to pollen and dust

Denies any allergies to medications or food

Family history:

Mother: DM and HTN diagnosed at 43, controlled with medications. Alive and well
Father: HLD diagnosed at 53, alive and well

Social history:

Habits:

Current smoker, about 1 ppd, about 25 pack yr history, occasional social alcohol use.
LK denies using any illicit drugs.

Travel:

Patients denies any recent travel

Marital history:

Patient is currently married to her husband for 15 years.

Occupational history:

Patient works at a grocery store

Sexual history:

LK is sexually active with her husband, and does not use condoms or any contraceptives. She denies any history of being tested for any STDs

Home:

She lives in a private home

Diet:

Patient eats a healthy balanced diet or chicken and vegetables

Exercise:

LK exercises 2-3 days a week, and is very active daily

Sleep:

Patient gets 7 hours of sleep a night

Safety:

Patient adheres to all safety practices.

Review of Systems:

Constitutional: denies any fatigue and diaphoresis, denies any headache, fever, loss of appetite, weight changes, or night sweats

Skin, hair, nails: denies changes in skin and hair texture. No lesions, or dryness. No discoloration, pigmentation, moles or rashes

Head: denies any lightheadedness and dizziness, denies any vertigo, or head trauma, fracture or coma

Eyes: patient does not wear glasses, last eye exam was over 3 years ago-normal. Denies any visual changes, double vision, photophobia, noncitric, or pruritis

Ears: denies decreased hearing, tinnitus, pain, lesions, discharge or use of hearing aids

Nose/sinuses: denies any discharge, epistaxis, or obstruction

Oropharynx: denies any lesions or ulcers, denies bleeding gums, dentures, erythema, tongue lesions, tonsillar exudate. Uvula midline. No changes in teeth. Last dental exam was 2 years ago-normal

Neck: neck is supple and nontender. She denies localized adenopathy or swelling. FROM. Thyroid midline

Breast: denies lumps, pain or nipple discharge

Pulmonary: denies dyspnea, shortness of breath, wheezing, orthopnea, cyanosis, hemoptysis, cough, accessory muscle use or paroxysmal nocturnal dyspnea.

Cardiovascular: denies any chest pain, palpitations, pedal edema, or known heart murmur.

Gastrointestinal: Admits to left abdominal pain and left flank pain, and nausea. Denies constipation, vomiting or diarrhea. Denies any changes to flatulence, eructation or acid reflux. Denies any melena or hematemesis.

Sexual history: as mentioned above

Genitourinary history: denies incomplete urination, frequency, dysuria, or urgency. Denies oliguria, nocturia, polyuria or flank pain

Nervous: denies loss of consciousness, denies seizures, sensory changes, motor loss, ataxia, loss of strength, change in cognition or memory

MSK: denies myalgias, swelling, redness, warmth, arthritis, or any joint or muscle pain.

PVS: denies coldness r trophic changes. No color changes or cyanosis. Denies peripheral edema or varicose veins. No intermittent claudication

Heme: denies bleeding or bruising easily, denies anemia or lymph enlargement. No history of DVT/PE

Endo: denies polyuria, polydipsia, polyphagia, heat or cold intolerance, goiter or hirsutism.

Psych: denies depression, anxiety, psychosis, OCD or ever seeing a psychiatrist.

Physical Exam:

Vitals:

Temp: 97.7F

BP: 120/87 (right arm supine)

HR: 84, regular

Resp rate: 19, unlabored

SpO2: 95 on room air

Height: 64 inches

Weight: 142 pounds

BMI: 24.37

General: good lightening and draping. Patient was alert and oriented x 3 to person, place and time. Patient had good hygiene, and looked appropriate age. Patient is in mild distress