Chronic Heart Failure and Dementia in Elderly Woman

SUBJECTIVE
This 89-year-old lady is seen at MCCRC on 03/28/2017. She was admitted here from Johnson City Medical Center on 03/23 after her second hospitalization for acute on chronic heart failure and a respiratory infection. She was sent home but instead of to a Rehabilitation Center when the family felt they could care for her then they could not get her out of bed. She has early dementia and much of her history is difficult to obtain, although she says that I had seen her mother some 30 years ago and prefers to talk about that era. She says she has never smoked. Her present medications at this facility include spironolactone 25 mg daily, a multivitamin, calcium, vitamin D, and vitamin K. She is on glucosamine. She is on citalopram

and she is on Lasix 20 b.i.d. for five days to be dropped to 20 mg daily. She is also on Xarelto for chronic atrial fibrillation 15 mg daily, Cipro 500 mg twice daily, Colace. She also says that her surgery in the past includes a broken arm and a hysterectomy. She says she lives with her family. She is from Shady Valley and worked for years in a factory in Bristol.

Review of systems is not reliable. Family history causes her to be embarrassed.

OBJECTIVE
On physical, she is a well-developed, fragile elderly lady appearing short of breath.

Her blood pressure earlier is 130/70. Her heart rate is irregularly irregular at about 115 beats a minute, SpO2 on two liters is 96, although her respiratory rate is 26. Temp is normal. Head, eyes, ears, nose and throat reveal no abnormalities. No temporal artery tenderness. Neck is supple. I see no JVD. I hear no carotid bruits. There is coarse rhonchi and wheezes bilaterally. I do not hear a rub. Consolidation is not well heard. Heart rhythm is irregular regular. PMI is displaced lateral on mid clavicular line. Abdomen is soft and nontender. The low ribcage impacts on the superior iliac crest bilaterally. No organomegaly is detected. There is a midline scar. There is trace ankle edema bilaterally and no calf tenderness. Peripheral pulses are reduced.

ASSESSMENT
1. Chronic atrial fibrillation.

2. Acute on chronic congestive heart failure.

3. Influenza A, recently diagnosed with ER visit over the weekend.

4. Chronic cognitive impairment, etiology unclear, possibly vascular.

PLAN
Will continue the present medications. We will watch carefully for bleeding problems. Will continue with physical therapy efforts to get her back on her feet. She may need further medication for controlling heart

rate.