CHANA KUMAR IHUMAN CASE:
FATIGUE OVER THE PAST TWO
MONTHS
Name: Chana Kumar
Gender: Female
Years: 86 years old
Type : IHUMAN CASE
ILLNESS:
... [Show More] 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.
Personal and Social History
Widowed x 20 years. Ms. Kumar lives alone and has an active social life. She has a support
system consisting of extended family and friends. She has three adult child (one deceased) that
lives nearby. She denies any tobacco use and will occasionally have a glass of on special
occasions.
Sexual History
Did not assess during the visit.
Review of Systems
General: Fatigue
HEENT & Neck: Negative
Cardiovascular: Heart Racing
Respiratory: Short of Breath
Gastrointestinal/Abdomen: Constipation
Genitourinary: Negative
Musculoskeletal: Weakness
Neurological: Negative
Integumentary (Skin, Hair, Breast): Negative
Allergic/Immunologic: Negative
Lymphatic/Endocrine: Negative
Hematologic: Negative
Psychological: Negative
Physical Exam
General Survey: Alert, in no acute distress.
Height: 5’2” Weight: 122 lbs.
Vitals: Temp: 98.2 F, HR: 110, BP: 138/92, RR: 16 Unlabored, O2: 95% Room Air
HEENT & Neck: Normocephalic, pupils PERRLA, conjunctival rim pallor, trachea midline, no JVD.
Cardiovascular: HR 110, Murmur – Early Systolic
Respiratory: Chest is symmetrical, no increase work of breathing.
Gastrointestinal/Abdomen: Soft, non-tender, non-distended. Normal bowel sounds.
Genitourinary: Did not examine at this time, no complaints per patient.
Musculoskeletal: Normal bulk and tone. No Rigidity. Range of motion is equal bilaterally.
Neurological: Alert and Oriented x4. CN II through XII is intact.
Integumentary (Skin, Hair, Breast): Skin is warm and dry. Palmer crease pallor.
Allergic/Immunologic: No Allergies
Lymphatic/Endocrine: No Adenopathy
Hematologic: No Bruising
Psychological: [Show Less]