Date of exam: 2/6/2023
Chief Complaint: “I am tired all the time”
HPI: This is a 59 y/o Hispanic female who presents today c/o being tired x3 months. She also reports worsening sob upon exertion x3 weeks, headaches and elevated blood pressure x 1 week. She reports a slight “Twinge” of pain in her chest yesterday that lasted about 1 minute. Pain was non-radiating and dull rating a 3/10 on pain scale. Headache is constant at right frontal area, dull and throbbing at times, pain is a 2/10 now and admits to taking Tylenol with relief. Last took Tylenol at 09:00 this morning (4 hours ago).
Past Medical/Surgical History:
CAD, HTN, HDL, DM, Depression
Cardiac stents x6. Most recent 2, placed 11/2019
Allergies: NKA
Medications: Metformin850 mg daily, glyburide 1.25 mg daily, Plavix 75 mg daily, metoprolol 25 mg daily, losartan 25 mg daily, Coreg 12.5 mg daily, Cymbalta 40 mg daily and Xanax 0.25 mg every 8 hrs as needed.
Family History: Father is alive in good health. Mother died at age 69 from MI. Pt reports extensive cardiac disease on father’s family. No siblings
Personal History: Works as Unit Secretary at a community hospital
Social History: Quit smoking 5 years ago, denies use of illicit drugs
Alcohol use: Denies current use. Reports previous alcohol abuse and now sober for 1 year.
Immunization: current, Flu vac this season 9/2022, Covid 19 vac 2023
Review of Systems
Constitutional: Denies weight loss, fevers, chills. Reports being very tired and requiring naps, reports recent 5 pounds weight gain.
Dermatologic: No rashes, reports dry skin on legs and arms.
Eyes: Denies blurry, double or change in vision, wears glasses.
ENT: Denies change in hearing, not congested, denies pain in sinuses.
Respiratory: Reports SOB on exertion, ex-smoking x5 yrs, denies lung disease, asthma, allergies and cough
Cardiovascular: c/o mild chest pain yesterday lasting one minutes, reports high blood pressure (monitor at home) and + cardiovascular diseases.
Gastrointestinal: Reports slight decrease in appetite, denies n/v, diarrhea, abdominal pain or constipation,
Musculoskeletal: reports feeling weak, denies joint swelling or tenderness
Psychiatric: Reports history of depression, denies feeling sad or depressed
Neurological: Reports + headaches. Denies dizziness, numbness, tingling, weakness or loss of sensation
Physical Examination
Vital Signs
Temp- 98.6 F (oral), HR- 68, RR-12, O2-92% ( RA), B/P- 168/92 (lying), Height 5’ 8”, Weight 166 lb BMI 27.5
General: Patient is a well-dressed, well-nourished 59 y/o female with clear speech appearing to be comfortable and in no distress
Skin: On observation, no cyanosis, petechiae, or ecchymosis. Warm to touch, intact throughout, good turgor, color appropriate for race.
Head: Normocephalic, atraumatic, face symmetrical. Hair distribution even.
Eyes: On examination/inspection, both eyes are anatomically symmetrical. Periorbital region clear without redness or discharge or exudate. Pink conjunctiva, anicteric sclera. There is no extropian or entropion, ptosis of the lid, squint, or strabismus, or corneal opacities. Both pupils are 3mm round, equal and brisk to light and accommodation. Visual field and acuity are normal. Vision 20/20 both eyes with use of Snellen chart, no signs of color blindness. Consensual light reflex is positive. Extraocular muscles are intact. With funduscopic examination, no hemorrhage, soft or hard exudates, no proliferation of vessels. Optic disc is reddish yellow in color with no bulging. Disc margins sharp, no cupping of the disc. There is no AV nicking or aneurismal dilatation of the blood vessel. No signs of increase intraocular pressure. On palpation no masses noted.
Cardiovascular: On examination, chest is symmetrical, no scars, no JVD, no displacement of PMI. No cardiac lifts, or heaves. Symmetrical expansion with respiration, no wall motions. On palpation, no thrills or palpable murmurs no abdominal aorta enlargement noted, PMI 5th LICS at MCL. On auscultation regular S1, S2, regular rate and rhythm, S1>S2 at apex. No S3, S4 noted. No friction rubs, gallops, murmurs or clicks noted. No carotid or abdominal bruits.
Thorax/Lungs: On examination, anterior and posterior chest and spine with normal curvature. No accessory muscle use (nasal flaring, intercostal retraction, or abdominal breathing), or cyanosis. On palpation, no tenderness or palpation, no consolidation, symmetrical breathing. Spine midline. No masses, well developed muscles and bones. On auscultation, lungs clear in all throughout lung field. No rales, stridor, rhonchi or wheeze. Vocal fremitus equal bilaterally. On percussion, no tactile fremitus or egophony. Resonance in all areas of the chest except for hepatic and cardiac dullness.
Gastrointestinal: On examination, abdomen symmetrical, flat with no lesions, scars, herniation or abnormal pulsations. On auscultation, normoactive bowel sounds in all four quadrants. No bruits or hums. On percussion, dullness noted throughout. On palpation, soft, non-tender and non-distended. No hepatosplenomegaly, no masses. Bladder soft, non-tender, and non-distended.
Neurological: CN 2-12 normal
Laboratory and Diagnostic Tests
Chest X-ray, EKG, CBC, CMP
Differential Diagnosis
Pulmonary Embolism, CHF acute exacerbation, Costochondritis
Diagnosis Pulmonary embolism, Symptoms include chest pain, dyspnea and a sense of apprehension. Syncope occurs at times.
Diagnosis: Pulmonary Embolism
PLAN:
Call 911- ED STAT
Continue: Metformin 850 mg daily, glyburide 1.25 mg daily, Plavix 75 mg daily, metoprolol 25 mg daily, Losartan 25 mg daily, Coreg 12.5 mg daily, Cymbalta 40 mg daily and Xanax .25 mg as needed.
continue diet and exercise.
Have patient follow up after hospital evaluation
in 7 days
Referral
Consult with cardiology.
