Reference no: EM133915017

Question : differential diagnosis list with at least 3 possibly actual diagnosis based on findings.

HPI: 97 y.o. F presented to HU Clinic for follow up trouble sleeping. First noticed the sleep dysfunction when she was hospitalized three months ago with acute exacerbation of heart failure. Since then she has been waking up frequently at night. She denies trouble lying flat, weight has been stable, and no swelling. She denies CP or SOB. She reports not having issues with initiating sleep, but it is maintaining sleep. She wakes up and lays in bed for hours until she falls back to sleep. She has noticed this causes her to have increase daytime sleepiness. She is wanting to try something to help her sleep since she is frustrated at this point and it has never been an issue. Past medical history: HFpEF, HTN, HLD, CAD Allergies: Cephalosporin, PCN, Carbapenems. Medications: Metoprolol Succ 50 mg PO daily. Lasix 40 mg PO daily. Atorvastatin 40 mg PO daily. ASA 81 mg PO daily. Amlodipine 10 mg PO daily. Lisinopril 10 mg PO daily. Tylenol 500 mg PO Q6H as needed for generalized pain. Social history: Lives in assisted living. Usually active walking laps around apartment complex with rolling walker. Has four adult children who live close by and visit her weekly. She denies tobacco, alcohol, and illicit drug use. Family history: Was adopted does not know biological family. Health Promotion: UTD on routine screening, prevention and vaccinations. Last PCP appt 1 month ago for follow up after hospitalization: CBC, BMP, TSH, BNP, Lipid panel, EKG check and in normal limits. Review of system General - Denies fever, chills or dizziness. She has been sleeping more during the day. Goes to bed around 8PM without issues, then wakes around 12AM. She lays in bed until around 4AM and usually falls back to sleep. Skin - denies rash and skin ulcer HEENT -denies hearing and vision loss, headache Neck - denies swelling and stiffness Cardiovascular - denies chest pain/tightness palpitations, heart racing Pulmonary - denies shortness of breath, cough Gastrointestinal - denies abdominal pain, nausea, vomiting, and diarrhea. No change in appetite, weight gain or loss. Genitourinary - Reports increase urination in the morning with Lasix but denies burning or blood. Peripheral vascular - denies discoloration and edema Musculoskeletal - denies muscle and joint ache Neurological - denies confusion, memory loss, numbness or tingling. Denies lightheadedness or feeling of faintness. Psychological - denies anxiety, depression and confusion. Feels stressed from not sleep because it is affecting her during the day and not walking daily like she typically does. Endocrine: Denies weight loss or weight gain. Hematologic: Denies bruising or bleeding easily. Objective Data Vital signs:. T- 98.6 F, HR- 59 RR- 19, BP - 132/76 mmHg Pulse ox - 96%, Wt.: 165 lbs. Ht 62 in General appearance: No acute distress, well-nourished and cleanly kept. HEENT: Normocephalic, face symmetrical. PERRLA. Auditory canal intact and clear. Hearing intact. Oral mucosa moist without ulcerations or lesions. Uvula midline. Dentures. Neck: Non-palpable, non-tender lymph nodes. Thyroid gland without enlargement or nodules. CV: Regular rate, rhythm, S1/S2. Lungs: Bilaterally clear to auscultation, no adventitious sounds. No clubbing noted. Abdomen: Bowel sounds present in all four quadrants, abdomen is soft and non-tender, no guarding, no rebound, no enlargement, or organomegaly noted. Genitourinary: No suprapubic or CVA tenderness. PV: B/L, equal +2 distal pulses. Capillary refill less than 3 seconds. No swelling, erythema or ulcerations on exam. No edema. MSK: Active and passive ROM within normal ranges. Uses rolling walker without issues. Neuro: Alert and oriented to person, place, date and situation. Appropriate conversation. Strength 5/5 throughout. Cerebellar Rapid alternating movements intact. Psychiatric: Behavior appropriate for the age. Thoughts are coherent Neurological: Alert, oriented, cooperative. Speech is clear. Oriented to person, place, and time.