Siddharth Shah
Rotation 1 – Internal Medicine

Identifying Data

January 18^th, 2023 – 10:00 AM
MM 47 F, African American Queens, NY
Informant: Patient, reliable

Chief Complaint: Chest Pain, diarrhea, chills vomiting, and syncope episode.

History of Present Illness:

47 y/o F with PMHx of seizures, osteoarthritis, spinal stenosis of lumbar region, iron deficiency anemia, and PSHx of myomectomy, and hysterectomy. Presents to the ED for chest pain, syncope, diarrhea, and chills. Last night patient was watching TV when she went to the bathroom and felt severe palpations, and clenching chest pain radiating to the left arm described as 10/10 pain. Patient has been experiencing pain like this for a few months, but not as severe. Patient reports it comes, and goes, and sitting down makes it better. Patient did not take any medication for the pain. Patients report on-and off exertional dyspnea when walking a block for a few weeks, and recently started using 3 pillows to sleep, and has not seen her PMD for any of these symptoms. Patient reports that last night she also had non-bloody vomiting episodes, chills, and diarrhea and was perfusing sweating. The patient is also reporting her memory from last night is scattered. Patient spouse and daughter mentioned patient had an episode of LOC, and had some twitching, and an episode of incontinence. Patient also endorses mild headache and nausea. Patient denies, abdominal pain, edema, and fever.

Past Medical History:

• Seizures
• Osteoarthritis
• Spinal stenosis of lumbar region
• Iron deficiency anemia
• Breast cyst

Past Surgical History:

• Myomectomy
• Hysterectomy

Medications:

• Gabapentin 300mg 2x a day
• Iron pills as needed.

Allergies:

• NKA

Family History:

• Breast cancer maternal aunt
• Prostate cancer, and glaucoma in father
• Mother as no known medical issues

Social History:

• No history of smoking or present
• Social drinker

Review of Systems:

General:  Endorses Chills. Appears alert and orientated. Has appetite.

Skin: Denies changes in texture, excessive dryness or sweating, discolorations, pigmentations, moles/rashes, pruritus, or changes in hair distribution.

Head: Endorses headache

Eyes: Denies visual disturbances, double vision, blurriness, excess tearing or dryness, photophobia, or pruritis.

Ears: Denies hearing loss, tinnitus, discharge, earache.

Nose and sinuses: Denies discharge, obstruction, allergies, or epistaxis

Mouth and throat: Denies sore throat, bleeding gums, ulcerations.

Neck: Denies localized swelling, lumps, stiffness, or decreased range of motion.

Pulmonary: Endorses dyspnea. denies wheezing, or productive cough.

Cardiovascular: Endorses chest pain and palpitations

Gastrointestinal: Endorses abdominal pain, vomiting, and diarrhea.

Genitourinary: Denies incontinence, dysuria, nocturia, urgency, oliguria, or polyuria.

Nervous: Patient endorses episode of syncope

Musculoskeletal: Endorses lower back pain

Peripheral Vascular: Denies peripheral edema, intermittent claudication, or varicose veins.

Hematologic: Endorses Right leg swelling. Denies History of DVT/PE.

Endocrine: Denies heat/cold intolerance, excessive sweating.

Psychiatric: Negative history of depression and anxiety. Denies having SI/HI

Physical Exam:

General: Patient lying on bed in no acute distress.

Vitals: Provided by Nurse

• BP(Seated): 77/49
• P: 87bpm, regular
• R: 20breaths/min, unlabored
• T: 37.2C oral
• O₂ Sat: 95 Room air
• Height: 5’6– Weight: 145lb – BMI: 23.4

Skin: IV on right arm clean, and dry. No erythema. No jaundice.

Hair: Average quantity and distribution.

Nails: No clubbing, capillary refill <2 seconds in all four extremities

Head: Slight tenderness on right side of head. Otherwise, head is non-traumatic.

Eyes: No strabismus, sclera white, cornea clear, conjunctiva pink.

• Visual corrected – 20/20 OS, 20/20 OD, 20/20 OU
• Visual fields full OU.  PERRLA, EOMs intact with no nystagmus

Ears: No masses, lesions, or deformities on external ears.  No discharge or foreign bodies in external auditory canals AU. TM’s white and intact with light reflex in good position AU.

Mouth:

• Lips: Dry with chapped lips.
• Mucosa: Pink with no masses or lesions. Non-tender to palpation.
• Palate: Intact with no masses or lesions Non-tender to palpation; continuity intact.
• Gingivae: Pink. No hyperplasia; masses; lesions; erythema or discharge.
• Tongue: Pink; well papillated with no masses or lesions. Non-tender to palpation.
• Oropharynx: Well hydrated, no masses, lesions, or foreign bodies. Uvula pink, no edema

Neck: Trachea midline. 2+ Carotid pulses, no stridor, thrills, or bruits noted bilaterally.

Thyroid: Nontender to palpation, no masses, no bruits noted.

Chest: Symmetrical, no deformities or trauma. Respirations unlabored, no paradoxical respirations or use of accessory muscles noted. Non-tender to palpation throughout.

Lungs: Slight diminished breath sounds heard on right lung.

Heart: Carotid pulses are 2+ bilaterally without bruits. RRR, S1 and S2 are distinct with no murmurs, S3 or S4.

Abdomen: Some abdominal tenderness. Bowel sounds are present in all 4 quarters. There is no tenderness, rebounding and guarding.

Peripheral Vascular: Edema noted on right leg. Skin normal in color and warm to touch upper and lower extremities bilaterally.

Musculoskeletal: No erythema, soft tissue swelling, or tenderness present on bilateral upper extremities. Tenderness felt on right leg, no tenderness felt on left leg.

Neurologic:

• Mental Status: Alert and oriented to person and place only. Speech spontaneous, and fluent. Naming and repetition intact. Follows complex commands.
• Motor: Normal bulk and tone. No abnormal movements. No pronator drift, finger taps rapid and symmetric.
• Sensory: Intact to light touch and temperature in all four extremities.

Differential Diagnosis:

1. MI
2. Pulmonary Embolism
3. Congestive heart-failure
4. Seizure
5. gastroenteritis

Assessment: 47 y/o F with PMHx of seizures, iron deficiency, and PSHx of myomectomy, and Hysterectomy. Presents to the ED for chest pain, syncope, and vomiting. Patient will be admitted.

Plan:

IV fluids – Patient blood pressure is low.

CBC with differential to check for infection, maybe sepsis, possible low H&H.

FOBT – to check for any bleeding

BMP to check for renal function, and electrolyte imbalance.

EKG to r/o MI

Serial troponin every 6 hrs

CXR to r/o pleural effusion.

CT head non-contrast because of patient LOC

D-dimer to r/o PE

Consult neuro for EEG as patient has history of seizures.

Patient Education:

Ms. MM you are being admitted today to internal medicine for a full-work up. Before we discharge you, we want to make sure you don’t have any serious conditions that need to be addressed immediately. Given the severeness of your chest pain, your dyspnea from walking, and using three pillow to go to sleep we are worried you may be having heart issues, so we would be ordering EKG, Troponin, and a chest x-ray to make sure your heart is okay, and there is no fluid. We will also get a CT scan of your head to make sure there is no bleeding in your brain due to your syncope episode. Also, we will have you speak with neurology and get an EEG as it sounds like you might’ve had seizure episode and may need your dosage or drug adjusted.