HISTORY
AND PHYSICAL
CHIEF COMPLAINT:
Chest pain.
HISTORY OF PRESENT
ILLNESS: This
61-year-old woman with a history of panic disorder has noticed
a 2-3 day history of pain in her neck and some malaise. She has also had occasional fullness retrosternally, lasting
up to one minute. This
morning she awoke with this retrosternal heaviness, with
radiation to the shoulder blade, neck and left arm that lasted
several hours. One
or two of these symptoms may have occurred episodically in the
past. She is not
very physically active and there is no history of reproducible
exertional angina, paroxysmal nocturnal dyspnea, dyspnea on
exertion, or edema.
MEDICATIONS:
1. Xanax 0.25 mg
b.i.d to t.i.d.
2. Zoloft 50 mg
daily
3. Zocor 40 mg
daily
4. Aspirin one daily
ALLERGIES:
No known drug allergies.
PAST MEDICAL
HISTORY: She
sees Elvis Presley, PA, for her primary care.
1.
Panic attacks since 1984, feels they have been
worsening as she has been under increased stress from recent
family illnesses.
2. History of
elevated cholesterol.
3.
Status post bilateral tubal ligation in 1968.
4.
Status post tonsillectomy in the third grade.
5.
Describes a loss of vision in the right eye in August
2001. According to the patient, she saw three ophthalmologists and
then saw Dr. Bugs Bunny. She
describes having carotid Doppler studies and being told to
take one aspirin. We
will try to obtain those records.
SOCIAL HISTORY:
She smoked one pack of cigarettes per day for 35 years. No alcohol or illicit drug use.
FAMILY HISTORY:
Mother died at 74 with diabetes mellitus, hypertension,
and multiple sclerosis. Father
died at 69 from complications from a ruptured appendix.
One sister has psychiatric problems.
One brother has diabetes mellitus and alcohol problems.
REVIEW OF
SYSTEMS: She
reached menopause at age 40.
She used to travel for a marketing company, but she has
not worked since October 2001.
She has had a sleep disturbance and several symptoms
consistent with the panic disorder.
No change in bowel or bladder habits.
Otherwise review of systems is negative.
PHYSICAL
EXAMINATION: Afebrile.
Blood pressure 120/70 in both arms.
Pulse 70. HEENT:
Pupils equal, round and reactive to light. Fundi normal. Mouth
and throat clear. NECK:
No adenopathy or jugular venous distention.
Carotids 2+, no bruits.
LUNGS: Clear
to auscultation and percussion.
Pectus excavatum present.
No chest wall tenderness.
Normal S1 and S2, no murmurs, gallops or rubs.
ABDOMEN: Normal
bowel sounds. Soft,
nontender. No
masses or hepatosplenomegaly.
EXTREMITIES: No clubbing, cyanosis, or edema.
Pulses 2+. No
skin breakdown. Mood
and affect anxious.
RADIOGRAPHIC/ACCESSORY
DATA: Chest x-ray normal. Electrocardiogram
incomplete right bundle branch block with no acute change.
LABORATORY DATA:
WBC 6.4, hemoglobin 12.5, hematocrit 39, platelets
339,000. Sodium
139, potassium 3.9, chloride 108, bicarb 24, BUN 11,
creatinine 0.7, glucose 139. Liver function tests normal.
CK 96, MB 4.2, troponin 0.01.
ASSESSMENT AND
PLAN:
1.
Chest heaviness off and on for the past three days.
At this point, there are no acute electrocardiogram
changes and enzymes are negative.
I suspect this is most likely secondary to her panic
disorder, as she has several symptoms of increasing anxiety
secondary to several illnesses in close family members.
However, she is 61 years old and a long-time smoker,
and for that reason will be admitted to chest pain observation
area. We will
draw serial enzymes and obtain a stress echocardiogram in the
morning. This was discussed with the patient and she was agreeable.
2. Panic disorder.
Continue Xanax and Zoloft and check TSH.
3. Probable history
of elevated cholesterol, as she is on Zocor. Liver enzymes were normal.
Will check a fasting lipid panel in the morning.
4. History of
vision loss in the right eye.
We will try to obtain the records from Dr. Bugs Bunny.
I do not hear any carotid bruits.
5. Mildly elevated
random blood sugar. We
will check a hemoglobin A1c as she has been told she has
borderline diabetes mellitus.
|
