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HISTORY OF PRESENT ILLINESS

Patient is a 60-year-old African-American female that's presenting with a one-month history of shortness of breath. Patient report's a shortness of breath have progressively gotten worse within the last week. Report's chest tightness to have started within the last week. Onset of shortness of breath, patient reports to have occurred before the chest tightness and lasted after the chest tightness had gone away. Patient reports that the shortness of breath and chest pain occur only with activity. Patient denies shortness of breath or chest pain at rest. Patient reports the chest tightness to last a couple of minutes and is sharp at times. Chest tightness is located on the left side of the chest with no radiation to the jaw, back, arm or neck. Patient reports the chest pain to be relieved with rest. Patient reports that the chest pain is worse with activity. Patient reports four-pillow with apnea that has been getting worse over the last month. Patient reports a positive history P & D, and has never had an evaluation for sleep apnea. Patient also reports a 5-lb weight gain in the last month. Patient reports increased swelling in her lower extremities bilaterally. Patient report's palpations at times. Patient also reports wearing O² at night. Patient denies nausea, vomiting, diaphoresis, fever, chills, numbness and tingling in the extremities.

PAST MEDICAL HISTORY

1. Hypertension.

2. CHF.

3. COPD-bronchitis.

4. Diabetes type II.

5. Depression/anxiety.

PAST SURGICAL HISTORY

1. Appendectomy.

2. Colonectomy.

3. Hysterectomy.

4. Total knee replacement, left knee.

FAMILY HISTORY

Dad is deceased at 40, secondary to an auto accident. Mom is alive at 87 with diabetes type II and hyertension. Patient reports having two brothers. One 55 years of age with hypertension, another brother who had an MI at the age of 49.

SOCIAL HISTORY

Patient reports to be divorced. She has two children, who are alive and well. Patient reports ½ a pack per day smoking history, for forty years. Patient reports that she quit. Patient denies drug use. Patient reports having a couple of beers on the weekends.

ALLERGIES

Penicillin. Verapamil.

MEDICATIONS

Potasium chloride.

Cozaar 50mg daily.

Coumidyn 5mg daily.

Glyburide.

Metformin.

Vitiam D.

Calcium.

Afciphex.

Prozac.

Diazepam.

Digoxin.

Flexeril.

Lasix.

Garlic.

Metolazole.

Patient is a full code.

REVIEW OF SYSTEMS

Patient denies any color changes, diaphoresis, problems with bleeding. Patient denies any muscle pain, weakness or paralysis. Patient denies any headaches, vertigo syncope, or pre-syncope symptoms. Patient denies visual lose phobia, ___________(sounds llike) upastacks, dental problems, change in voice, neck swelling or stiffness. Patient denies any recent cough, cold, sore throat, or earache. Patient denies any change in appietie, naseau, vomiting. Patient denies any uninary symptoms. Patient denies any change of bowel habits. All other positive ROS, please see HPI. Patient's cardiac risk factors: patient has a positive family history of high blood pressure, and diabetes. Patient is a smoker. Patient has a history of hypertension, and diabetes. Patient is a female over the age of 55. The last stress and CAT are unknown as far as the cardiac work-up.

PHYSICAL EXAMINATION

VITAL SIGNS: Tempature 97.1, pulse is 58, blood pressure 114/56. Admit weight 201 lbs.

GENERAL: No acute distress. Patient is sitting up comfortable.

HEENT: Pupils equal round and reactive to light. Normal symstalic atramatic. Moist mucus membranes. No signs of infection.

NECK: Supple. No lymphadenopathy. Carotids are brisk; no buries. JVD is deferred due to the patient sitting up.

LUNGS: Cleared to osculation bilaterally

NECK: Cardiac irregular rate and rhythm. A variable S1. Positive S2. Questionable murmur.

ABDOMEN: Obese. Non tender. Positive bowel sounds.

EXTREMITIES: Trace ankle edema bilaterally. No synopsis or clubbing. Alert and oriented x 3. Cranium nerves: 2-12 grossly intact. Patient moving all extremities well.

Peripheral vascular: + 2 radial dorsalis pedis, pulse is bilaterally.

LABORATORY

Sodium 138, potasium 3.5, BUN 18, creatinine 0.8, albumin 5.2, white blood count 9.9, A/G 1.8

ASSESMENT/PLAN

1. Shortness of breath is acute, rule-out PE. V2 scan will be done.

2. Chest pain, rule-out acute coronary syndrome, cardiac serum markers and EKGs. Patient has multiple risk factors for coronary artery disease including obesity, hypertension, diabetes type 2. A stress test will also be evaluated.

3. Afibrillation. Patient's right controlled, questionable length of time. He has received one dose of Lovenax last night.

4. Diabetes type 2. Accu-cheks AC and HF.

5. Hypertension is controlled.