CHANA KUMAR IHUMAN CASE: FATIGUE OVER THE PAST TWO MONTHS
Name: Chana Kumar
Gender: Female
Years: 86 years old
Type : IHUMAN
... [Show More] CASE
ILLNESS: Fatigue
Content : physical exams, MSAP, exercise
: questions, diagnosis, DDX, DDX
: rankings, MNM, Case plan
Chana Kumar H&P
Patient Information
Chana Kumar is an 86-year-old female.
History is provided by the patient, who is a reliable source.
Chief Complaint
Patient presents with the chief complaint of fatigue over the past two months.
Present Illness
Ms. Kumar stated that she had an alarming situation during her water aerobics class yesterday. She stated she gradually became shorter of breath and her heart started racing. When her instructor checked her heart rate, it was 120 beats per minute. She said her symptoms improved after resting for 30 minutes. Ms. Kumar has a history of hypertension in which is taking metoprolol 100mg daily and aspirin 81mg daily. She had a CABG performed 8 years ago. She also takes atorvastatin 20mg daily for her high cholesterol.
Ms. Kumar also states that she has been feeling more fatigued, weaker, and easily winded over the past two months. She feels good waking up in the morning but gets tired throughout the day. She does get tired walking up stairs and around the block. Denies having difficulty with performing activities of daily living. She does states she has pain in her knees but that is due to her osteoarthritis. She takes ibuprofen 600mg as needed for pain.
Ms. Kumar also has an ongoing problem of constipation. She takes OTC bowel cleanses as needed. She states her problem with constipation has gotten worse. She denies any changes to her bowels or abdominal pain. She denies any other health problems other the acid reflux, which is well controlled with esomeprazole 40mg daily.
Patient is normally healthy and denies being around anyone sick or any recent travels.
Past Medical History Hypertension x20 Years Coronary Artery Disease x8 Years Gastroesophageal Reflux Disease Hypercholesterolemia
Coronary Artery Bypass Graft 8 Years Ago G4P4
Allergies
No known Allergies
Medications
Metoprolol 100 mg Daily Aspirin 81 mg Daily Esomeprazole 40 mg Daily Atorvastatin 20 mg Daily
Ibuprofen 600 mg As Needed for Pain OTC Bowel Cleanses
Health Maintenance
Patient is up to date on her immunization.
Last gynecological exam with PAP smear "many years ago." Last colonoscopy 8 years ago (normal).
Normal mammograms in the past.
Family History
Her mother died of stroke at age 76. Her father died of MI at age 78.
She does not have siblings. [Show Less]