SUBJECTIVE: The patient comes in today accompanied by her son, secondary to language barrier, for concerns about increasing pain and increasing shortness of breath. The patient, for the past month or two, has had sensations of increasing shortness of breath that has limited her activities. However, she also has significant pain related to her rheumatoid arthritis that has also limited her activities.
At this time, the patient’s family is doing herbal treatments and some patches, which do seem to help. She is complaining of pain, worse in her hands, right elbow, left shoulder and right knee. The patient states that makes it difficult for her to walk.
She is status post a hip replacement on the right. She is currently taking at least 4 Darvocet a day with minimal relief. She is also continuing on her rheumatoid arthritis medication.
The patient does have a longstanding history of cardiac issue. She has a pacemaker in for third-degree heart block, which had been complicated by some congestive heart failure.
She also has a history of asthma. She has been using Advair as well as Combivent inhalers at home. According to the patient and the daughter, that has been making no difference in her breathing. She does note that if she sits quietly, she does not have any breathing difficulties, but on any activity, even getting up from the wheelchair to the exam table in my office, she does become short of breath.
She is not running a fever. She has no urine symptoms; although, she notes she has urinary frequency but no odor and burning. Her appetite is good. Her weight is stable. Her medications have not changed.
Son states that she believes her pacemaker was interrogated two months ago and that it was stable.
Past medical history includes atrial fibrillation, cardiomyopathy with congestive heart failure, rheumatoid arthritis, shortness of breath.
Current medications include atenolol 25 mg daily; folic acid 1 mg daily; furosemide 20 mg one day, 40 mg the next day; omeprazole 20 mg daily; Plaquenil 300 mg daily; prednisone 7.5 mg daily; Darvocet daily; warfarin adjusted dose.
OBJECTIVE: Blood pressure 142/52. Heart rate 50 and regular. Pulse oximetry 98%. Respiratory rate is 20. There is no pedal edema present. Lungs: Basically clear. Heart: Regular. S1, S2, distant heart sounds.
ASSESSMENT: Increasing shortness of breath.
PLAN: Review of her chart reveals that she has baseline anemia, likely related to renal insufficiency. We are not clear if that is worse and contributing to her shortness of breath or the fact that her heart rate is a little bit low, in the 50s, that is contributing to shortness of breath. We discussed getting x-ray, changing her inhalers. The patient is declining to do this. At this time, the patient is requesting DO NOT RESUSCITATE status and looking for comfort measures. After discussion with Dr. John Doe, the plan will be:
1. CBC, TSH, iron level, chemistry screen, BNP, urinalysis and culture.
2. We will consult Dr. Jane Doe’s office for reevaluation of pacemaker, whether heart rate needs to be elevated, but the settings need to be increased.
3. Chest x-ray: The patient declined.
4. Continue inhalers: Again, the patient declined.
5. Fentanyl patch 25 mcg. We did discuss with her and the son that may help her pain and allow for increasing mobility and will follow up pending cardiology evaluation and lab evaluation.
