with palpitations for the last two days. Says that she feels her heart
racing and states that she feels her blood pressure went up as well over
the last couple of days. Denies any chest pain. She has feeling like its
fluttering. Denies any shortness of breath. She got Ativan and fluids in
the Emergency Room. Says that she got upset when a couple of guys came
around her apartment building with a gun and she says that she got scared
and the whole complex along with her got scared as well. Says she heard
them again at the hospital ##### in the Emergency
Room today. She did not see them but states she heard them saying that
they wanted to kill her and rape her. She says that the apartment complex
has reported this incident to the ####### Police Station as well.
Denies hearing any voices at present but she says that she is very anxious
right now. She never had any similar complaints of hearing people or
hearing voices ever. Denies any headache. Says that she feels very tired.
Says that she has not been sleeping well over the last couple of days. Has
had no appetite and has not eaten for the last three days. She says that
she has lost about 25 pounds in the last six months.
Recently she was changed from her blood pressure medication - she is not
sure what she is taking now - states about two weeks ago her primary care
physician changed her medication. States having a sore throat as well for
the last two days and has been taking over-the-counter lozenges for that.
Says that she feels slightly feverish but has not measured her
temperature. States she is coughing up some whitish expectoration on and
off for the last two days now.
RECENT AND PRESENT MEDICATIONS: (Dosage and Frequency)
She is not sure of her medications but states that she takes:
1. Dalmane for the last six months or so.
2. Tramadol.
3. Aspirin.
4. We will get her medication reconciliation from her primary care
physician's office in the AM.
PAST HISTORY: (Operations, Injuries, Illness; include dates and relative
details as known- Immunization and Dates)
1. Hypertension.
2. Denies any diabetes, cancer in the past or previous heart
problems.
3. Her medical record is not available at the moment but cardiac
catheterization done in September of 2003 shows normal arteries and
some possible cardiomyopathy.
SOCIAL HISTORY: (Lifestyle/Occupation, Marital status, Children, and Risk
Factors)
Never smoked. Denies excessive alcohol use, statues she drinks
occasionally. Denies any illegal use.
FAMILY MEDICAL HISTORY:
Significant for coronary artery disease and hypertension in her mother.
Her mother passed away because of some heart problems at 84 years of age.
She is not sure what she had. Her father had hypertension. A sister has
diabetes.
PRESENT REVIEW OF SYSTEMS: (Unless otherwise noted, areas are
noncontributory)
ALLERGIES/SENSITIVITIES: Denies any allergies to any medications.
SKIN AND LYMPHATIC: No recent skin rashes.
CENTRAL NERVOUS SYSTEM (Include special senses): Denies any
headaches. Denies any recent change in mentation.
RESPIRATORY: Some cough with some whitish expectoration on and off.
CIRCULATORY: Denies any chest pain or shortness of breath.
DIGESTIVE: Moving bowel pretty okay, last bowel movement was
yesterday. Denies constipation. Low appetite and has not eaten for
the last three days as per history of present illness.
GENITOURINARY: Denies dysuria, polyuria.
METABOLIC AND ENDOCRINE: Denies any cold or heat intolerance.
HEMATOLOGIC: Denies easy bruising.
MUSCULOSKELETAL: Some back pain on and off. Denies any other pain.
PSYCHIATRIC: States she feels very anxious but denies being depressed.
(PHYSICAL EXAMINATION)
GENERAL APPEARANCE:
She is alert and oriented X3, pleasant lady to speak with who is lying
anxiously in bed and wants us to close the door behind us whenever we exit
the room as she is scared and anxious.
TEMPERATURE: 98.9 PULSE: 122
BLOOD PRESSURE: 159/88 lying - AGE:
standing 155/99
HEIGHT: RESP: 18 WEIGHT:
Saturation 93%
on room air
SKIN: Normal. No rashes seen.
LYMPH NODES: No lymphadenopathy.
HEAD: Normocephalic and atraumatic.
EARS: Normal. No discharge. Normal hearing.
EYES AND FUNDI: PERRLA.
NOSE: No discharge. No nasal septal deviation.
MOUTH, TEETH, AND THROAT: Normal.
NECK: Supple. No thyromegaly. No JVD. No carotid bruits.
CHEST: Bilateral equal expansion to respirations.
BREASTS: Deferred.
LUNGS: Normal vesicular breath sounds. No added sounds. No wheezes.
No rales.
HEART: S1, S2 heard. No murmurs. Tachycardia. Normal rhythm.
ABDOMEN: Soft. Nontender. No organomegaly appreciated. Bowel sounds
present.
HERNIA: None seen.
BACK: Some tenderness in the back but no costovertebral angle
tenderness elicited.
EXTREMITIES: 1-2+ edema in bilateral lower extremities. Bilateral
pulses palpable equally. No cyanosis or clubbing.
NEUROLOGICAL: Cranial nerves II thru XII grossly intact. No
neurological deficits. Sensation to touch. Pain and temperature
grossly intact. Strength 4-5/5 in all extremities. No cerebellar
signs.
GENITALIA-PELVIC: Deferred.
RECTAL: Deferred.
Pertinent laboratory data; sodium 140, potassium 3.6, chloride 103, bicarb
19, BUN 55, creatinine 1.7, glucose 109, WBC 5.3, hemoglobin 11.7,
hematocrit 35.3, platelets 222. CPK 277, CK MB 5.9. CK MB index 2.1.
Troponin T less than 0.03.
IMPRESSION(S):
1. Palpitations for the last two days. Could be multifactorial may be
secondary to dehydration or withdrawal from benzodiazepines. Could
be secondary to anemia as well. Will give her Ativan for her
anxiety. Will get a urine drug screen. Will give patient IV fluids.
********
2. Hypertension. Monitor blood pressure for now and get medication
list from primary care physician's office. Will give her Lopressor
12.5 milligrams.
3. Paranoia. Was her main complaint. Will need further
evaluation. She has history of weight loss. May need a MRI for
possible frontal lobe tumor. Will get psychiatric evaluation.
4. Renal insufficiency. Chronic versus prerenal. Will get inputs
and outputs. Will get urine electrolytes, urine sediments, urine
eosinophils. Will get old records. Will give fluids.
5. Elevated cardiac enzymes. Has tachycardia probably contributing
to the elevation. Will cycle enzymes. Will watch for any signs of
acute coronary syndrome.
6. Anemia. Microcytic. Will Hemoccult the stools. Will get
iron panel and ferritin.
7. DVT prophylaxis with SCD given.
Addendum: Overnight patient slept under the bed, and in the morning when I went to see her she was eating her breakfast under the bed because she was afraid the 2 men are going to come after her. She also wanted to leave the hospital, and threatened me and one resident that she knows karate and can take us down easily
Care e diagnosticul vostru diferential si ce altceva ati vre sa faceti pentru acest pacient (a fost facut dar am pus **** in loc).
PS. are partial legatura cu discutia de aici: viewtopic.php?f=3&t=7153&st=0&sk=t&sd=a&start=280 , cu pacientul psihotic
