HISTORY:
Date & time: 04/12/22 8:00 am
Full Name: Mrs. S
Address: Flushing, NY
DOB: 01/15/1957
Age: 65 y/o
Sex: Female
Race: African American
Religion: Christian
Source: Pt. herself
Transportation: Self
Reliability: Reliable
Location: New York Presbyterian Queens
Chief Complaint: “My chest hurts when I breathe in” x 2 days
History of Present Illness:
50 y/o female with PMH of hypothyroidism and hypertension presents to ED c/o of chest pain for 2 days. Pt. states that she was sitting at home in the afternoon when she had a sudden onset of chest pain that was located in her mid chest region. She describes the pain as a sharp pain that occurs with inhalation and lasts until expiration. The pt. denies any alleviating or aggravating factors and states that the pain does not radiate anywhere. She describes her pain as a 6/10 in severity. Pt did not take any medications for the pain prior to arriving at the ED. Pt. states she was prescribed Lisinopril 1 month ago after being diagnosed with HTN from her PCP, however she stopped taking the medication 1 week prior to symptom onset. Pt. states she has never experienced similar symptoms in the past. Pt. reports that the morning of her symptom onset she began feeling chills and began coughing up yellow sputum. Pt reports associated SOB, nausea, fatigue, and a decrease in appetite that began the same day as symptom onset. Denies family history of MI, personal history of MI, recent trauma, strenuous activity the days prior, palpatitations, syncope, fever, wheezing, vomiting, sick contacts or diaphoresis.
Past Medical History:
- Hypothyroidism x 20 years, controlled medically.
- Hypertension x 1 month, currently uncontrolled.
- Immunizations up to date; flu vaccine yearly (unknown date); Covid vaccines and booster up to date (unknown dates).
- Past Hospitalizations: None
Past Surgical History:
- Thyroidectomy 20 years ago, due to an unknown reason, no complications.
- Gastric sleeve 25 years ago, due to obesity, no complications.
- Denies past injuries or blood transfusions.
Medications:
- Synthroid 125mcg PO QD for hypothyroidism, last dose this am.
- Lisinopril 10 mg PO QD for hypertension, last dose 1 week ago.
- Denies use of herbal supplements.
Allergies:
- NKDA
- Denies seasonal, food, or animal allergies
Family History:
- Mother – age 88 alive and well
- Father – alive age 89 h/o diabetes and HTN
- Maternal/paternal grandparents – deceased at unknown age & unknown reasons
- Daughter – age 30 alive and well
- Son – age 25 alive and well
Social History:
- Habits- Pt. denies h/o of smoking or tobacco use along with illicit drug use. Pt. also denies alcohol and caffeine use.
- Travel- Pt. denies any recent travel.
- Marital history- Married to husband for over 20 years.
- Occupational history – Unemployed.
- Home situation – Lives with husband in 1 bedroom apartment.
- Diet- Pt. states that her diet consists of mainly fried and salty foods.
- Exercise- Pt. states her only exercise consists of walking up the stairs at home.
- Sexual Hx: Heterosexual, pt. states she is sexually active with her husband and uses barrier protection with condoms. Denies h/o sexually transmitted disease.
- Safety measures – Admits to seat belt use.
Review of Systems:
General – Admits to generalized fatigue, chills, changes in appetite. Denies fever, night sweats, weight loss or gain.
Skin, hair, nails – Denies changes in texture, excessive dryness, pigmentations, moles/rashes, pruritus, or changes in hair distribution, excessive sweating.
Head – Denies headaches, vertigo, dizziness, or head trauma.
Eyes – Last eye exam 2021, visual acuity unknown. Denies glasses or contact usage, visual disturbances, photophobia, lacrimation, or pruritus.
Ears – Denies deafness, pain, discharge, tinnitus.
Nose/sinuses – Admits to rhinorrhea and sinus pain. Denies obstruction, or epistaxis.
Mouth/throat – Admits to sore throat. Last dental exam unknown. Denies bleeding gums, sore tongue, mouth ulcers, or voice changes.
Neck – Denies localized swelling/lumps or stiffness/decreased range of motion.
Breast – Last mammogram 2021, unremarkable. Denies lumps, nipple discharge, or pain. Pulmonary system – Admits to dyspnea and cough. Denies dyspnea on exertion, orthopnea, paroxysmal nocturnal dyspnea, wheezing, or cyanosis.
Cardiovascular system – Admits to chest pain and h/o HTN. Denies palpitations, irregular heartbeat, edema/swelling of ankles or feet, syncope, known heart murmur.
Gastrointestinal system – Admits to changes in appetite and nausea. Admits to normal bowel movements 1-2 times per day. Last colonoscopy exam October 2019, unremarkable. Pt. denies change in bowels, vomiting, abdominal pain, jaundice, hemorrhoids, constipation, diarrhea, rectal bleeding.
Genitourinary system – Admits to urinary urgency, nocturia, and oliguria. Denies urinary frequency, polyuria, dysuria, incontinence, flank pain.
Menstrual/Obstetrical- G2, P(T2 P0 A0 L2), menarche age 15, LMP age 51. Denies hot flashes/associated menopause symptoms, breakthrough bleeding, vaginal discharge.
Nervous – Denies migraines, seizures, loss of consciousness, sensory disturbances, ataxia, loss of strength, changes in cognition / mental status / memory, or weakness.
Musculoskeletal system –Denies muscle/joint pain, deformity or swelling, or redness.
Peripheral vascular system – Denies intermittent claudication, coldness or trophic changes, varicose veins, peripheral edema, or color changes.
Hematological system –Denies anemia, lymph node enlargement, blood transfusions, or history of DVT/PE.
Endocrine system – Denies polyuria, polydipsia, polyphagia, heat or cold intolerance, excessive sweating, hirsutism, or goiter
Psychiatric – Denies depression/sadness, anxiety, OCD or ever seeing a mental health professional.
Physical:
General: heavy set female, neatly groomed, appears her stated age of 65.
Vital Signs: BP: R L
Seated 148/90 146/92
R: 17/min, unlabored P: 87 beats/min, regular
T: 98.6 degrees F (oral) O2 Sat: 98% Room air
Height: 65inch Weight: 315 lbs BMI: 37.3
Skin: warm & moist, good turgor. Nonicteric, no lesions noted, no scars.
Hair: average quantity and distribution.
Nails: no clubbing, capillary refill <2 seconds throughout.
Head: normocephalic, atraumatic, non-tender to palpation throughout
Nose: symmetrical / no masses / lesions / deformities / trauma / discharge. Nares patent bilaterally / Nasal mucosa pink & well hydrated. No discharge noted on anterior rhinoscopy. Septum midline without lesions / deformities / injection / perforation. No foreign bodies.
Sinuses: non tender to palpation and percussion over bilateral frontal, ethmoid, and maxillary sinuses.
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 / no obvious dental caries noted.
Gingivae – Pink; moist. No hyperplasia; masses; lesions; erythema or discharge.
Tongue – Pink; well papillated; no masses, lesions or deviation.
Oropharynx – Well hydrated; no injection, exudates, masses, lesions, or foreign bodies.
Tonsils grade 1 present with no injection or exudates. Uvula pink, no edema or 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 cervical adenopathy noted.
Thyroid – Non-tender; no palpable masses; no thyromegaly; no bruits noted.
Ears: Symmetrical and appropriate in size. No lesions/masses/trauma on external ears. No discharge / foreign bodies in external auditory canals AU. TM pearly grey / intact with light reflex in good position AU. Auditory acuity intact to whispered voice AU. Weber midline / Rinne reveals AC>BC AU.
Eyes: Symmetrical OU. No strabismus, exophthalmos, or ptosis. Sclera white, cornea clear, conjunctiva pink. 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 AV nicking, hemorrhages, exudates, or neovascularization OU.
Chest: Symmetrical, no deformities, no trauma. Respirations unlabored / no paradoxical respirations or use of accessory muscles noted. Lat to AP diameter 2:1. Non-tender to palpation throughout.
Lungs: Decreased breath sounds bilaterally (preceptor said this was due to weight of pt.). Clear to percussion bilaterally. Chest expansion and diaphragmatic excursion symmetrical. Tactile fremitus symmetric throughout.
Heart: JVP is 2.5 cm above the sternal angle with the head of the bed at 30°. PMI in 5th ICS in mid-clavicular line. Carotid pulses are 2+ bilaterally without bruits. Regular rate and rhythm (RRR). S1 and S2 are distinct with no murmurs, S3 or S4. No splitting of S2 or friction rubs appreciated.
