Identifying Data:

Name: Mrs. O

Sex: Female

Address: Arverne, NY

Date of Birth: 9/23/1985, 36 years old

Date & Time: 10/12/21, 11:30 AM

Location: Southshore Family Medical, Arverne, NY

Marital Status: Married

Race: African American

Source of Information: Self

Reliability: Reliable

Mode of Transport: Car

Chief Complaint: “I have chest pain” x 5 days

History of Present Illness: 

36 yo female w/ PMH Type 2 DM, HLD, nephrolithiasis, appendicitis, obesity, and vit D deficiency, presents with chest pain and heart palpitations x 5 days. Pt went to St. Johns ER on Thursday when pain and palpitations began, had negative workup, and was advised to follow up with PCP.  She states the CP and palpitations came on suddenly one morning, are constant, and not improving or worsening. Pt describes the pain as a sharp substernal pain, radiating to her sides, and rates it as 10/10. States the pain is worse at night when she lies down, denies alleviating factors. Admits taking aspirin 81 mg last night with no relief. Also admits to heartburn, SOB. Denies HA, fever, dizziness, cough, sore throat, nasal congestion, N/V/D, abdominal pain. 

Past Medical History:

Present medical illnesses – Type 2 DM, HLD, obesity, vitamin D deficiency

Past Illnesses- Nephrolithiasis (2017), Appendicitis  (2012)

Childhood illnesses – none

Immunizations – Up to date

Screening Tests- none

Blood Transfusions- none

Past Surgical History: Appendectomy, 2012

Hospitalization: Appendectomy, 2012

Medications:

1. Metformin HCl 500 mg tablet, 1 tablet with a meal QD, for Type 2 DM
2. Lipitor 40 Mg tablet, 1 tablet PO QD, for HLD
3. Ergocalciferol 5000 Unit, 1 capsule Po, 1x/ week, for Vitamin D deficiency

Allergies:

No known food, drug, or environmental allergies.

Family History:

Mother – 61, has HLD

Father – 64, has Type 2 DM

Daughter- 14, alive and well

Daughter, 11, alive and well

Maternal/paternal grandparents – Deceased at unknown age and unknown reasons

Social History:

Mrs. H is a 36 y/o married female. She is works for delta at JFK airport. She lives at home with her husband and daughter.

Habits – Patient drinks one cup of coffee every morning. Denies smoking, ETOH use, use of e-cigarettes or any illicit drug use. 

Travel- Denies any recent travel.

Safety- Admits to wearing seat belt.

Sleep – Admits to sleeping well, for about 8 hours every night.

Exercise – Denies getting regular exercise.

Diet- Patient maintains a low carb diet. Admits to 

Sexual History: Monogamous, admits to being currently sexually active. Denies history of sexually transmitted infections.

Review of Systems:

General – Denies loss of appetite, recent weight loss or gain, current generalized weakness, fatigue, fever, chills, or night sweats.

Skin, hair, nails –Denies changes in texture, excessive dryness or sweating, discolorations, pigmentations, moles/rashes, pruritus or changes in hair distribution.

Head – Denies dizziness, headaches, vertigo or head trauma, unconsciousness, head fracture or coma.

Eyes –Denies use of glasses or contacts, visual disturbances, fatigue, lacrimation, photophobia, and pruritus. 

Ears –Denies ear pain, discharge, or use of hearing aids.

Nose/sinuses – Denies discharge, obstruction or epistaxis.

Mouth/throat – Denies sore throat, sore tongue, bleeding gums, mouth ulcers, voice changes. 

Neck – Denies localized swelling/lumps or stiffness/decreased range of motion

Breast- Denies lumps, nipple discharge, and pain.

Pulmonary system – Admits to shortness of breath. Denies dyspnea cough, wheezing, orthopnea, paroxysmal nocturnal dyspnea, cyanosis or hemoptysis.

Cardiovascular system – Admits to chest pain, palpitations. Denies hypertension, irregular heartbeat, syncope or known heart murmur.

Gastrointestinal system – Admits to pyrosis. Denies changes in appetite, intolerance to foods, abdominal pain, nausea, vomiting, diarrhea, constipation, flatulence, dysphagia, eructation, jaundice, hemorrhoids, rectal bleeding, or blood in stool. 

Genitourinary system –Denies urinary frequency, urgency, polyuria, oliguria, nocturia, incontinence, dysuria, hesitancy, dribbling, or flank pain.

Musculoskeletal system – Denies muscle/joint pain, arthritis, deformity or swelling, or redness.

Nervous System–Denies seizures, loss of consciousness, ataxia, loss of strength, change in sensation/tingling/ numbness, change in cognition / mental status / memory, or asymmetric weakness.

Peripheral vascular system –  Denies peripheral edema, intermittent claudication, coldness or trophic changes, varicose veins, or color changes.

Hematological system – Denies anemia, easy bruising or bleeding, lymph node enlargement, or history of DVT/PE.

Endocrine system –Denies polyuria, polyphagia, polydipsia, heat or cold intolerance, excessive sweating, hirsutism, or goiter.

Psychiatric –Denies recent stressful factors, depression, anxiety, OCD or ever seeing a mental health professional.

 Physical Exam

General: 36 year old female, alert and oriented to person, place and time. Patient is of obese build, is well dressed, well groomed, and has good hygiene. Patient appears in no acute distress.

Vital Signs: BP: 120/80, sitting                      

R: 14 breaths/min unlabored     

P: 66 beats/min, regular       

T: 97.2 Degrees F (oral)                      

O2 Sat: 97% on Room air

Height: 66 inches            Weight: 218 pounds        BMI: 35.18 (obese)

Skin- Warm and moist, smooth, good turgor, nonicteric. No lesions, masses, scars, tattoos, thicknesses or opacities.

Hair- average quantity and distribution. Coarse, no lice or seborrhea noted.

Nails- Normal color size and shape of the nails. No spooning, clubbing, beau’s lines fissures, paronychia noted. Capillary refill <2 seconds throughout hands and toes.

Head-Atraumatic, normocephalic. Nontender to palpation on the frontal, temporal, occipital, and parietal areas. No deformities or specific faces noted.

Thorax & Lungs 

Chest – Symmetrical, no deformities, no evidence of trauma. Respirations are unlabored, no paradoxical respirations or use of accessory muscles noted. Lat to AP diameter 2:1. Non- tender to palpation. 

Lungs – Clear to ausculatation and percussion bilaterally. Chest expansion and diaphragmatic excursion symmetrical.

Abdomen-Abdomen flat and symmetric with no striae, scars or pulsations noted. Bowel sounds normoactive in all four quadrants with no aortic/renal/iliac or femoral bruits. Abdomen soft and non-tender to palpation across all 4 quadrants, no guarding or rebound noted. No hepatosplenomegaly to palpation, no CVA tenderness appreciated. 

Heart-Regular rate and rhythm. No splitting of S2 or friction rubs appreciated. Carotid pulses are 2+ bilaterally without bruits.

Mental Status Exam- patient is alert, attentive, and oriented. Speech and language are clear and fluent with good word comprehension. Appears to be in good mood, has insight and judgment into her medical problems. Memory and cognitive ability intact, gave accurate information upon assessment of history.

Peripheral Vascular Exam- no edema, equal in circumference, no calf tenderness. Skin normal in color and warm to touch upper and lower extremities bilaterally. . No palpable cords or varicose veins bilaterally. No palpable inguinal or epitrochlear adenopathy. No cyanosis, clubbing / edema noted bilaterally.

 Labs/ Imaging

 EKG showed normal sinus rhythm, bloodwork was performed and sent to lab.

Assessment

36 yo female w/ PMH Type 2 DM, HLD, nephrolithiasis, appendicitis, obesity, and vit D deficiency, presents with chest pain and heart palpitations x 5 days. Patient in no acute distress, EKG and PE were normal. 

Differential Diagnoses

1. Pulmonary Embolism- patient has chest pain, palpitations and SOB. However, no risk factors for PE ( recent long travels, OCP’s), legs are normal (no sign of DVT), did full workup in hospital and everything was normal, EKG is normal.
2. Myocardial Infarction- patient has chest pain that radiates to sides, palpitations, SOB, and heartburn. However, normal EKG, workup in hospital was normal. 
3. Arrhythmia- patient has CP, palpitations, and SOB. EKG came back normal, but could be inaccurate because only measures what is going on currently with patient and arrhythmias could come and go.
4. GERD- pt has CP, heartburn, worse at night. However, no difficulty swallowing, regurgitation. 
5. Stable Angina- has CP, SOB, and palpitations. However, is constant and not worse after activity. 
6. Anxiety- Has palpitations, SOB, which could be caused by anxiety. However, denies recent stressful events or stressful triggers, denies feelings of anxiety upon questioning.

Plan

1. Chest Pain/Palpitations/SOB-referral to cardiology. Advise patient to return to clinic or go to ED if symptoms worsen.
2. Heartburn- referral to gastroenterologist. 
3. Obesity- educate on harms associated with obesity, importance of exercise and healthy eating habits, consider referral to nutritionist
4. Type 2 DM- no acute complaints, continue metformin
5. HLD- no acute complaints, continue lipitor
6. Vitamin D Deficiency- no acute complaints, continue cholecalciferol