Aileen Alvarez 2/7/2023 PAC-Lab SOAP for Chana Kumar Student Name: Aileen Alvarez, PA-S Patient Name: Chana Kumar Date of Service: 2/7/2023 Age/DOB 86-yr-old (XX-XX-XXXX) Sex Female Use of Interpreter: None Reliability Patient; Good historian SUBJECTIVE

Aileen Alvarez 2/7/2023 PAC-Lab SOAP for Chana Kumar Student Name: Aileen Alvarez, PA-S Patient Name: Chana Kumar Date of Service: 2/7/2023 Age/DOB 86-yr-old (XX-XX-XXXX) Sex Female Use of Interpreter: None Reliability Patient; Good historian SUBJECTIVE *Chief Complaint: Fatigue that has not been resolved only escalated for the last 2 months. HPI: Mrs.Kumar is an 86-year-old Indian female patient who is presenting to the clinic because of acute shortness of breath during physical activities and fatigue that has exceeded for 2 months. She recently experienced palpitations during her first water aerobics class. A checkup was done on her heart rate, and it was at 120 beats per minute but subsided after 30 minutes. She is feeling normal in the morning portions of the days but gets tired as the day progresses. However, has currently denied having any difficulty managing her typical activities during her daily routine. Mrs. Kumar is normally healthy but has been dealing in her own way with chronic constipation; has not been on any recent trips or been exposed to sick people. Past Medical History: Hypertension -Takes metoprolol prescribed by provider. Coronary Artery Bypass Graft (8 years ago) Coronary Artery Disease (8 years ago) -Takes aspirin as prescribed by provider. Gastroesophageal Reflux Disease -Takes esomeprazole for her reflux as prescribed by provider. Hyperlipidemia -Takes atorvastatin as prescribed by provider. Osteoarthritis This study source was downloaded by from CourseH on :36:30 GMT -05:00 -Takes ibuprofen per need if pain radiates beyond comfort per provider prescription. G4P4: Gravidity and Parity Medications: HTN= Metoprolol 100 mg, PO, 1 daily, Active CAD=Aspirin 81 mg, PO, 1 daily, Active HLD= Atorvastatin 20 mg, PO, 1 daily, Active OA= Ibuprofen 600 mg, PRN, PO, Active GERD= Esomeprazole 40 mg, PO, 1 daily, Active OTC Bowel medications, Active Allergies: NKDA Social History: No tobacco being used, only having one glass of wine when special occasions arise. Sexual History: Was not asked on this visit, but the patient has been a widow for the last 20 years. Family History:  Mother deceased at 76 because of stroke.  Father deceased at 78 from a myocardial infarction.  Siblings: None  Grandparents: Unknown history for both sides.  Children: Three living adult children; one deceased due to an accident. OBJECTIVE Physical Examination: Height: 5'2 Weight: 122 lbs. BMI: 22.3 Vitals: Temp: 98.2 F, HR: 110 BPM, BP: 138/92 mmHg (normotensive/lying down/L side), RR: 16 Unlabored, O2: 95% RA General Survey: Alert and orientated x 4, in no acute distress per my visual aspect of her. HEENT & Neck: Normocephalic pupils had a PERRLA, trachea midline, conjunctival rim pallor, but no JVD. Cardiovascular: Her heart rate was at 110, also heard a murmur which could hint at early systolic signs. This study source was downloaded by from CourseH on :36:30 GMT -05:00 Respiratory: Chest is symmetrical with no tedious labored breathing patterns noticed. Gastrointestinal/Abdomen: Normal bowel sounds noted but also there is non-tenderness just soft touch. Genitourinary: Not evaluated on this visit. Musculoskeletal: She had a normal bulk and tone, with no rigidity and a positive range of motion bilaterally. Neurological: Alert and Oriented x4 which is a plus with her age and checked her cranial nerves I through XII as well. Integumentary: Her skin was warm and dry. Palmer crease pallor. Immunologic: No significant physical signs were noticed for this category. Lymphatic/Endocrine: No adenopathy has been reported. Hematologic: No unknown bruises or bleeding issues came up or were visible during the visit. Psychological: Pleasant and appropriate mood throughout the visit. Labs: CBC R.68.8 WBCs- 6800 mm3 (Reference: 4,000-10,000) RBCs- 4.3 million/µg (Reference: Male= 4.5-5.9/Female=4.0-5.2 adults) Hgb- 8.5 g/dl (Reference: Male=14-18/Female=12-16 adults) Hct- 25.1% (Reference: Male=42-54/Female=37-47 adults) MCV- 78 fL (Reference: 82-103 adults) MCH- 22 µm3 (Reference: 26-34 adults) Platelets- 243 k/dL (Reference:150-399 adults) RDW- 17.8% (Reference: 11.5-14.5 adults) Neutrophils: 65% (Reference: 46-78 adults) Lymphocytes: 25% (Reference: 18-52 adults) Monocytes: 5% (Reference: 3-10 adults) Eosinophils: 5% (Reference: 0-6 adults) Basophils: 0% (Reference: 0-3 adults) Segmented neutrophils: 63% (Reference: 36-72 adults