Identifying Data:

Name: Mrs. L

Sex: Female

Address: New York

Date of Birth: 46 Years Old

Date & Time: 2/9/21

Location: Statcare Urgent Care, Hicksville, NY

Marital Status: Married

Race: African American

Source of Information: Self

Reliability: Reliable

Source of Referral: Self

Mode of Transport: Car

Chief Complaint: “I have heart palpitations” x 2 weeks

History of Present Illness:

Mrs. L is a 46 year old, obese female with a past medical history of diabetes, iron deficiency anemia, and thyroid disease, who presented to the Statcare Urgent Care complaining of heart palpitations for 2 weeks. She states that the palpitations began suddenly 2 weeks ago, and were on and off, but got worse yesterday morning while she was at work, when she also felt SOB. She was not doing anything in particular when the palpitations began, and described the sensation as a feeling of “my heart beating too fast.” She stated that at the time of her palpitations yesterday, her blood pressure was 164/86, her heart rate was 133, and her blood sugar was 208, so she left work. She explained that the palpitations are intermittent, and can last anywhere from a few minutes to a few hours, and she does not currently feel them in the office. She stated that she felt a sharp chest pain yesterday which did not radiate anywhere, but does not currently have any pain, and she rated the severity of palpitations as an 8/10. She said that the palpitations get worse when she lays on her side, and better when she lays on her back, and denied taking any medication for relief. She explained that she had these palpitations once before, two years ago, when she went to her endocrinologist and was diagnosed with anemia. She admits to intermittent SOB over the past few weeks, which worsens when she does strenuous activity, and denies current chest pain, dizziness, fatigue, weakness parasthesias, diaphoresis, or syncope.

Past Medical History:

Present medical illnesses – Diabetes, Iron Deficiency Anemia

Past Illnesses- Thyroid Disease, 5 years ago, resolved

Childhood illnesses – none

Immunizations – Up to date

Screening Tests- none

Blood Transfusions- none

Past Surgical History:

Ceasarean section, 2009, no complications

Ceasarean Section, 2016, no complications

Medications:

Metformin 500 mg 3x daily, for DM2. Last dose this morning.

Ferrous Sulfate 325 mg 3x daily, for Iron Deficiency Anemia. Last dose this morning.

Vitamin C- 500 mg 1ce daily, for overall health. Last dose yesterday.

Allergies:

No known food, drug, or environmental allergies.

Family History:

Mother – 71, Alive and Well

Father – Deceased at unknown age and unknown reasons

Daughter- 11, Alive and Well

Daughter- 4, Alive and Well

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

Social History:

Mrs. L is a married woman who lives at home with her husband and young children. She works as a certified nursing assistant.

Habits- Patient drinks one cup of coffee a day. Denies past and present use of alcohol, cigarettes, tobacco, e-cigarettes, illicit drug use, and history of substance abuse.

Travel- Denies any recent travel.

Safety- Admits to wearing seat belt.

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

Exercise – States that she exercises a lot during work, as her job is very active

Diet- Patients maintains a balanced diet, generally eats healthy but sometimes eats snacks. Drinks 4 cups of water a day.

Sexual History: Heterosexual, monogamous. Currently sexually active. Admits to using contraception. Denies history of sexually transmitted infections.

Review of Systems:

General –Denies loss of appetite, recent weight loss or gain, 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, contacts, visual disturbances, fatigue, lacrimation, photophobia, and pruritus.

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

Nose/sinuses – Denies discharge, obstruction or epistaxis.

Mouth/throat –Denies dentures, bleeding gums, sore throat, sore tongue, 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 and dyspnea on exertion. Denies cough, wheezing, orthopnea, paroxysmal nocturnal dyspnea, cyanosis or hemoptysis.

Cardiovascular system –Admits to palpitations. Denies hypertension, chest pain, edema/ swelling of the ankles/feet, irregular heartbeat, syncope or known heart murmur.

Gastrointestinal system –Denies changes in appetite, intolerance to foods, abdominal pain, diarrhea, constipation, nausea and vomiting, dysphagia, pyrosis, flatulence, 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, deformity or swelling, redness or arthritis.

Nervous System– Denies seizures, loss of consciousness, sensory disturbances such as numbness, paresthesia, dysesthesias, hyperesthesia, ataxia, loss of strength, change in cognition / mental status / memory, or asymmetric weakness.

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

Hematological system – Admits to diagnosis of anemia 2 years ago.  Denies 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 anxiety, depression/sadness, OCD or ever seeing a mental health professional.

Physical Exam

General: 46 year old obese female, alert and oriented to person, place and time. Patient has good posture, is well dressed, well groomed, and has good hygiene. Patient appears very anxious.

Vital Signs:      BP: 130/76                 

R: 16 breaths/min unlabored     

P: 107 beats/min, regular     

T:97.4 degrees F (oral)                      

O2 Sat: 99% on Room air

Height: 64 inches               Weight: 189 pounds        BMI: 32.4

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.

Eyes-Symmetrical OU. Eyebrows and eyelashes even distribution, eyelids have no discharge or swelling, lacrimal glands have no excessive tearing, dryness, enlargement or erythema, lacrimal sac not inflamed or swollen. No evidence strabismus, exophthalmos or ptosis. Sclera white, conjunctiva ad cornea clear. 

Visual acuity uncorrected – 20/20 OS, 20/20 OD, 20/20 OU

Visual fields full OU. PERRLA, EOMs intact with no nystagmus. 

Fundoscopy – Red reflex intact OU. Cup to disk ratio <0.5 OU. No evidence of AV nicking, hemorrhages, papilledema, exudates, cotton wool spots or neovascularization OU. 

Ears- Symmetrical and normal size. No lesions, masses or trauma on external ears. No discharge/foreign bodies in external auditory canals AU. Tympanic membrane pearly white/intact with cone of light in normal position AU. Auditory acuity intact to whispered voice AU. Weber midline/Rinne reveals AC>BC AU.

Nose-Symmetrical, no masses lesions or deformities, trauma or discharge. Nares patent bilaterally, nasal mucosa pink & well hydrated. No discharge noted on anterior rhinoscopy. Septum midline without lesions, deformities, injection or perforation. No foreign bodies. 

Sinuses- Non-tender to palpation and percussion over bilateral frontal and maxillary sinuses. 

Mouth

Lips – Pink, moist; no cyanosis or lesions.

Mucosa – Pink; well hydrated. No masses; lesions noted. No leukoplakia.

Palate – Pink, well hydrated. Palate intact with no lesions; masses; scars.

Teeth – Good dentition and no obvious dental caries noted.

Gingivae – Pink; moist. No hyperplasia; masses; lesions; erythema or discharge.

Tongue – Pink; well papillated; no masses, lesions or deviation noted. Non-tender to palpation.

Oropharynx – Well hydrated; no injection; exudate; masses; lesions; foreign bodies. Tonsils present with no injection or exudate. Uvula pink, no edema, lesions. 

Neck – Trachea midline. No masses; lesions; scars; pulsations noted. Supple; non-tender to palpation.   FROM; no stridor noted. 2+ Carotid pulses, no thrills; bruits noted bilaterally, no lymph nodes appreciated.

Thyroid- Non-tender; no palpable masses; no thyromegaly.

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 auscultation and percussion bilaterally. Chest expansion and diaphragmatic excursion symmetrical. Tactile fremitus intact throughout. No adventitious sounds. 

Breast Exam –Breasts symmetric, no dimpling, no masses to palpation; nipples symmetric without discharge or lesions. No axillary nodes palpable.  

Abdomen-Abdomen flat and symmetric with some striae, and 2 scars from previous surgeries. No pulsations noted. Bowel sounds hyperactive in all four quadrants with no aortic/renal/iliac or femoral bruits. Tender to palpation throughout the right and left lower quadrants, tympanic throughout, no guarding or rebound noted. No hepatosplenomegaly to palpation, no CVA tenderness appreciated. 

Heart-Sinus tachycardia, normal rhythm. S1 and S2 are distinct with no murmurs, S3 or S4. No splitting of S2 or friction rubs appreciated. JVP is 2.5 cm above sternal angle with the head of the bed at 30 degrees. PMI in 5th ICS in mid-clavicular line and not greatly appreciated

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

Cranial Nerve Exam – CN I- correctly identifies coffee and mint odors bilaterally

CNII-visual fields full by confrontation, visual acuity 20/30 OD, 20/30 OS, 20/30 OU, uncorrected, red reflex present, no hemorrhages, exudates, or crossing phenomena

CN III, IV, and VI- extraocular movements intact, PERRLA, no ptosis

CN V- face sensation intact bilaterally, corneal reflex intact, jaw muscles strong without atrophy

CN VII- correctly identified sweet, salt, bitter and sour tastes, facial expressions intact, clearly enunciates words

CN IX and X- no hoarseness, uvula midline with elevation of soft palate, gag reflex intact, no difficulty swallowing

CN XI- full range of motion at neck with 5/5 strength and strong shoulder shrug

CN XII- tongue midline without fasciculations, good tongue strength

Peripheral Nervous System-

Motor/Cerebellar-Full active/passive ROM of all extremities without rigidity or spasticity. Symmetric muscle bulk with good tone. No atrophy, tics, tremors or fasciculation. Strength 5/5 throughout.  Romberg negative, no pronator drift noted. Gait steady with no ataxia. Tandem walking and hopping show balance intact. Coordination by rapid alternating movement and point to point intact bilaterally, no asterixis

Sensory-Intact to light touch, sharp/dull, and vibratory sense throughout.   Proprioception, point localization, extinction, stereognosis, and graphesthesia intact bilaterally

Reflexes-2+ throughout, negative Babinski, no clonus appreciated

Meningeal Signs-No nuchal rigidity noted. Brudzinski’s and Kernig’s signs negative

Peripheral Vascular Exam- Skin normal in color and warm to touch upper and lower extremities bilaterally.  No calf tenderness bilaterally, equal in circumference.  Homan’s sign not present bilaterally. No palpable cords or varicose veins bilaterally. No palpable inguinal or epitrochlear adenopathy. No cyanosis, clubbing / edema noted bilaterally.

Musculoskeletal: No soft tissue swelling / erythema / ecchymosis / atrophy / or deformities in bilateral upper and lower extremities. Non-tender to palpation / no crepitus noted throughout. FROM of all upper and lower extremities bilaterally.  No evidence of spinal deformities.  

Assessment – Mrs. L is a reliable, 46 year old female with a significant medical history of diabetes and iron deficiency anemia. She presents to Statcare Urgent Care complaining of heart palpitations that started 2 weeks ago and worsened yesterday morning, along with added shortness of breath.

Plan:

Problem List:

1. Heart Palpitations/ Shortness of Breath/tachycardia- Perform EKG. Order CBC, CMP, Thyroid Function tests. Refer to cardiologist for further testing. Educate patient on limiting caffeine intake. If due to anxiety, guide patient on performing relaxation exercises.
2. Diabetes- FS was high when taken yesterday, do repeat FS, if high again consider adding medication/ referral to endocrinologist. Educate patient on watching diet and limiting sugar intake.
3. Iron Deficiency Anemia- taking Iron supplements. Order CBC to ensure this issue is being fully corrected.
4. Obesity- educate on harms associated with obesity, importance of exercise and healthy eating habits, consider referral to nutritionist
5. Previous Thyroid Disease- resolved according to patient. Confirm by performing thyroid function tests.

EKG came back showing normal sinus rhythm, bloodwork was performed and sent to lab.

Differential Diagnoses

1. Arrhythmia- patient feels palpitations and has sinus tachycardia. EKG came back normal, but could be inaccurate because only measures what is going on currently with patient and arrhythmias could come and go.
2. Iron Deficiency Anemia- patient has palpitations, tachycardia, shortness of breath, and admits that the last time she felt this way she was diagnosed with iron deficiency anemia. However, denies headache, fatigue, weakness, dizziness, no pallor noted on physical exam.
3. Hyperthyroidism- patient has palpitations and tachycardia, and appears anxious and irritable. Also has previous history of thyroid disease. However, denies fatigue, heat intolerance, or irregular menstruation. Upon PE, no periorbital edema or exophthalmos.
4. Anxiety- patient has palpitations and tachycardia, and appears anxious, nervous and irritable. However, denies recent stressful events or stressful triggers, denies feelings of anxiety upon questioning.