SE 2.1 – H&P

Identifying Data:

C.W, 85YOF

Date & Time of Encounter: 2/9/2024 11:15

Chief Complaint: NA/Admission H+P

History of Present Illness:

85yof w/PMH of HTN, DM2 w/ neuropathy (a1c 7.7%), obesity, GERD, OA, CKD3, and asthma admitted to NYP on 2/5/24 after being found down >24hrs after unwitnessed mechanical fall at home. Pt reports she was ambulating home alone when she tripped over a pack of cans on her floor and was unable to get back up until her HHA found her the following day.

At NYP, PT found to have NSTEMI, dehydration w/ mild rhabdo, b/l LE edema, asymptomatic +UA. No acute traumatic injuries found. NSTEMI determined likely 2/2 demand, although TTE (+) for hyperdynamic LV, no intraventricular thrombus, and segmental WMA consistent with CAD. Lactate cleared and CK downtrended over hospital course. Edema improved. PT refused treatment for asx UTI. Lantus decreased from 15u to 8u, aspirin initiated. 

Today, PT seen and evaluated at bedside, A&Ox4, no signs of acute distress. States she is tired, but is feeling well otherwise. Reports worsening BLE pain 2/2 diabetic neuropathy, worse with palpation, R>L. Denies pain elsewhere. She has been ambulation with a walker and 1-assist, she is continent of stool but notes increasing urinary incontinence over the last year with increasing urinary frequency and urgency. Denies dysuria, flank pain, fever. Denies constipation. Says her appetite is less than prior to hospitalization, but that she believes she is still eating and hydrating adequately. Pt noted SpO2 92% on RA, denies h/o supplemental O2, denies palpitations, SOB, difficulty breathing, CP.


Present chronic illnesses – 

  1. HTN
  2. DM2 w/ neuropathy
  3. Obesity
  4. GERD
  5. OA
  6. CKD
  7. Asthma

Past medical illnesses – Depression in the 1960s, since resolved 

Childhood illnesses – Denies 

Immunizations – Up to date, including COVID-19 and influenza vaccines this year

Screening tests and results – Unknown

Past Surgical History:

  1. Hysterectomy
  2. Cataract Surgery w/ artificial lens


  1. metFORMIN HCl ER 500 MG, 1 tablet two times a day
  2. Irbesartan Tablet 150 MG, 1 tablet one time a day 
  3. Aspirin Oral Tablet Chewable 81 MG, 1 tablet one time a day
  4. Glimepiride Oral Tablet 1 MZG, 0.5 tablet one time a day 
  5. Famotidine Tablet 20 MG, 1 tablet two times a day
  6. Chlorthalidone Tablet 25 MG, 1 tablet one time a day
  7. Simvastatin Tablet 20 MG, 1 tablet at bedtime  
  8. SitaGLIPtin Phosphate Tablet 100 MG, 1 tablet one time a day  
  9. Latanoprost Solution 0.005 %, 1 drop in both eyes at bedtime  
  10. Carvedilol Tablet 12.5 MG, 1 tablet two times a day
  11. Nystatin Powder 100000 UNIT/GM, topically two times a day
  12. Brimonidine Tartrate Solution 0.15 %, 1 drop in both eyes three times a day
  13. Basaglar KwikPen Solution Pen-injector 100 UNIT/ML, 8 unit subcutaneously at bedtime  
  14. Acetaminophen Tablet 325 MG, 2 tablet every 8 hours as needed

Vitamins and Supplement: Denies


NKDA, denies food and environmental allergies.

Family History:

Grandparents, deceased at unknown ages from unknown causes

Mother, deceased at 81, DMT2

Father, deceased at 69, DMT2, HTN, AMI

Son, deceased at 54 from traumatic injury

She has two daughters, 61 and 64, alive and well

Social History

C.W. is widowed and lives alone in a studio in Manhattan. 

She receives assistance from an HHA 5 days a week, 4 hours a day. 

HHA completes all IADLs with the exception of finances.

Pt reports she is primarily independent in all ADLs, however, toileting, bathing, and putting on socks/shoes has become increasingly difficult over the last year.

She is a retired elementary school support staff member.

She denies alcohol intake.

She is a previous smoker, ~70 pack/years.

She has 2-3 cups of coffee daily.

She denies illicit drug use.

She denies recent travel.

She reports a diet sufficient in fruits and vegetables, says that majority of meals are home-cooked by HHA.

She reports a mostly sedentary lifestyle

She reports getting 7-8 hours of sleep each night. She notes quality has worsened since her hospitalization.

She is not sexually active.

Review of Systems:

General – Reports fatigue since hospitalization. Denies fever, weight loss, weight gain.

Skin, hair, nails – Reports dry skin on B/L LE painful to touch. Denies vascular changes, color changes, rashes, or skin lesions.

Head – Denies dizziness, syncope, or head trauma.

Eyes – Denies changes in vision, discharge, or erythema. Notes 20/20 vision after corrective cataract surgery.

Ears – Denies changes in hearing, pain, or discharge.

Nose/sinuses – Denies nasal congestion, sinus congestion or sinus tenderness.

Mouth/throat – Reports globus sensation after eating bacon that has since resolved. Denies sore throat or voice changes. Last dental exam 2021.

Neck – Denies swelling, tenderness, or stiffness.

Pulmonary system – Denies cough, wheezing, pleuritic pain, or dyspnea.

Cardiovascular system –  Denies CP, palpitations, edema. 

Gastrointestinal system – Reports she is eating less than usual since hospitalization. Denies abdominal pain, constipation, nausea, vomiting, diarrhea.

Genitourinary system – Reports urinary frequency and urgency with worsening incontinence over the past year. Denies dysuria or flank pain.

Nervous – Reports constant B/L LE neuropathy with worsening pain to touch. Denies ataxia, paresthesias, h/o CVA.

Musculoskeletal system – Reports generalized muscle weakness since hospitalization. Denies pain or abnormal range of motion.

Peripheral vascular system –  Reports B/L LE edema that has improved since hospitalization. Denies varicose veins or cold extremities.

Hematological system – Denies easy bruising or bleeding, h/o blood transfusions, or h/o DVT/PE.

Endocrine system – Denies heat or cold intolerance, excessive sweating, or excessive thirst.

Psychiatric – Reports depression in the 1960s that has resolved since. Denies anxious or  depressive mood.


Vital Signs: 

Wt: 227.2

Ht: 65”

BMI: 37.8

Temp: 97.8, oral

Pulse: 72 bpm, regular rate and rhythm 

Resp: 18 rpm, unlabored

Sp02: 92% on room air

BP: 120/74 Lying/L Arm

BGL: 236 mg/dL

General:  Well-nourished, neatly groomed Black female, A&Ox4, that looks her stated age, engaging appropriately with conversation. Pt appears comfortable, lying semi-fowlers in bed without signs of acute distress.

Skin, Hair and Nails: Dry, cracking skin on B/L forelegs. Skin is otherwise warm & moist with good turgor. Nonicteric, no lesions noted. No visible tattoos or markings. Hair is average quantity and distribution. Nails without clubbing, no discolorations, capillary refill <2 seconds in upper extremities B/L.

Head: Normocephalic and atraumatic.

Eyes: Symmetrical OU. No strabismus, exophthalmos or ptosis.  Sclera white, cornea clear, conjunctiva pink. Visual fields full OU. 

Ears: Symmetric and appropriate in size. No lesions, masses, or evidence of trauma on external ears. No discharge or foreign bodies in external auditory canals AU. 

Nose: Symmetrical with no masses, lesions, deformities, or trauma. Nares patent bilaterally. 

Sinuses: Non-tender to palpation and percussion over bilateral frontal, ethmoid and maxillary sinuses.

Mouth: Lips, oral mucosa, and palate pink, moist, no cyanosis or lesions. Good dentition with no obvious dental caries noted. Gingivae are pink and moist without hyperplasia or masses. Tongue is pink and moist without masses, lesions or deviation. 

Oropharynx: Well hydrated, with no exudates, masses, erythema, or lesions. Tonsils are present with no erythema or exudates. Uvula midline, with no lesions.

Neck: Trachea midline. No masses, lesions, scars, or visible pulsations noted. No palpable cervical adenopathy. Thyroid non-tender, no thyromegaly, no palpable nodules noted.

Chest: Respirations unlabored with symmetrical chest wall expansion. Non-tender to palpation throughout. 

Lungs: Mild crackles in lower lobes B/L, otherwise clear to auscultation without adventitious breath sounds.  

Heart: Regular rate and rhythm (RRR). S1 and S2 are distinct with no murmurs, S3 or S4.  No splitting of S2 or friction rubs appreciated.

Abdomen: Abdomen non-distended, all four quadrants are nontender to palpation, no guarding or rebound noted. Bowel sounds normoactive in all four quadrants with no aortic/renal/iliac or femoral bruits. No hepatosplenomegaly to palpation, no CVA tenderness appreciated. 

GU: Bladder is nondistended, no suprapubic tenderness.

Neurologic: Symmetric muscle bulk with good tone of upper and lower extremities. UE strength 4/5 B/L and LE strength 3/5 B/L.  No atrophy, tics, tremors or fasciculations appreciated. Intact to light touch and sharp/dull sensation throughout. Patellar Reflex 2+ B/L. Gait unable to be observed at time of exam.

Extremities (Peripheral Vascular/MSK): Mild, non-pitting edema of B/L calves and ankles (lateral>medial). Calf tenderness to light palpation B/L that PT reports is consistent with h/o diabetic neuropathy. No additional soft tissue swelling, erythema, ecchymosis, atrophy, deformities, tenderness or crepitus noted B/L. Skin is normal in color and warm to touch upper and lower extremities B/L, pedal pulses 2+. No palpable cords, varicose veins, cyanosis, or clubbing appreciated on LE B/L. 


85yof PMH of HTN, DM2 w/ neuropathy (a1c 7.7%), obesity, GERD, OA, CKD3, asthma, h/o cataracts w/ artificial lens b/l; hospitalized and treated after mechanical fall with associated NSTEMI, dehydration w/ mild rhabdo, b/l LE edema, asymptomatic +UA; deemed stable for hospital discharge and admission to SAR.


Problem List:

  1. NSTEMI likely 2/2 CAD
  2. BLE edema
  3. HTN
  4. HLD
    1. stop chlorthalidone 25mg QD given kidney dysfunction
    2. continue with aspirin 81mg
    3. continue with irbesartan 150mg QD
    4. continue with carvedilol 12.5 BID
    5. continue with simvastatin 20mg QD
    6. monitor BLE edema
    7. continue with weekly weights x 4 weeks
  5. hx of rhabdomyolysis 
  6. generalized muscle weakness
    1. continue with PT, OT, 1-assist with ADLs, careful OOB and ambulation with walker
  7. DM2 w/ neuropathy
    1. continue with metformin ER 500mg BID
    2. continue with basaglar 8u HS
    3. continue with sitagliptin 100 QD
    4. continue with glimepiride .5mg QD
  8. GERD
    1. continue with famotidine 20mg BID
  9. OA
    1. continue with APAP 325mg q8prn
  10. h/o cataracts, artificial lens b/l
    1. continue with latanoprost 1 drop HS
    2. continue with brimonidine 1 drop TID
    3. ophtho f/u prn
  11. CKD3
    1. avoid nephrotoxic agents
    2. monitor renal fxn