Setting: large rural clinic; family practice clinic that employs physicians, physician assistants and nurse practitioners.
You open the chart to review for your next patient, and you see it is Lorene M. Lorene is a 60 year-old African American female with a history of hypertension and known documented metabolic syndrome following lifestyle changes per her request. You note she is not due for a follow up at this time, so you look at the chief complaint.
CC: Shoulder discomfort and SOB with exercise 3 days ago.
You enter the room and introduce yourself to Lorene who is sitting in the chair. You ask what brings her in today. She smiles, shaking her head and says “My daughter made me come, I feel fine. I am way too busy to be here today. Since my last visit, three months ago, I joined a gym and with the support of my daughter, we are going two days a week.” However, three days ago Lorene felt short of breath while in dance class. She developed what she calls as “a discomfort” that radiated back and up between her shoulder blades while at the peak of her exercise routine. She also felt a little nauseous and sweaty. Once she stopped dancing, all symptoms resolved in about 3 minutes and they have not re-occurred.
PMHx: Reports general health as good. She has been trying to lose weight through exercise and avoiding processed foods. She admits that food is a large part of her background and heritage in social activities and so it is difficult to make healthy choices. She had been feeling great since starting to work out and has lost 2 inches around the abdomen. She describes having lots of energy until this episode three days ago. Now she is a little concerned because she feels a little more tired than usual. She has not participated in anything strenuous and has not worked out since
Childhood/previous illnesses: chicken pox.
Chronic illnesses: Hypertension, Metabolic Syndrome, and Dyslipidemia.(Lifestyle management was initiated per patient preference) Gestational Diabetes with 3 pregnancies managed with Insulin
Surgeries: T and A, cholecystectomy
Hospitalizations: None aside from surgeries listed above
Immunizations: Does not receive the flu shot.
Allergies: Reports remote Hx allergy to metformin. Describes a GI disturbance.
Blood transfusions: None
Current medications: None. Stopped Lisinopril one month ago as she read that it can cause a cough as one if its side effects. Prefers to get the BP under control with diet and exercise.
Social History: Married for 20 years. Children are grown and have moved out of the house but all live locally and are close to their parents. Lorene works full time as a CEO of a successful marketing company and travels often for work. She eats out a lot while entertaining business clients. She enjoys beer and wine and the occasional “social” cigarette when she gets together once weekly with her girlfriends.
Family History: Parents are deceased. Father had lung cancer and mother died from complications of a stroke due to complications of diabetes type 2. Brother died at 44 from malignant melanoma. Other sister and brother are healthy but they also have diagnoses of metabolic syndrome.
Height: 5’8″ weight: 220 pounds; BMI 33.5 vital signs: BP 146/90 P 70 Sao2 97% Random glucose finger stick in office: 130mgs/dl
General: African American female in NAD. Alert, oriented, and cooperative. Pain: 0/10 at present
Skin: Skin warm, dry, and intact. Skin color is light skinned brown, no cyanosis or pallor.
HEENT: Head normo-cephalic. Hair thick and distribution even throughout scalp.
Eyes: Sclera clear. Conjunctiva: white, PERRLA, EOMs intact. No AV nicking noted.
Ears: Tympanic membranes gray and intact with light reflex noted. Pinna and tragus non-tender
Nose: Nares patent without exudate. Sinuses non-tender to palpation, Right-sided Deviation
Throat: Oropharynx moist, no lesions or exudate. Teeth in poor repair, gums reddened and receding, filled cavities noted. Tongue smooth, pink, no lesions, protrudes in midline.
Neck supple. No cervical lymphadenopathy or tenderness noted. Thyroid midline, small and firm without palpable masses. Mild JVD in recumbent position
Lungs: Lungs clear to auscultation bilaterally. Respirations unlabored. No rashes or vesicles noted on chest.
CV: Heart S1 and S2 noted, RRR, no murmurs, noted. No parasternal lifts, heaves, and thrills. Peripheral pulses equally bilaterally. PMI 5th ICS displaced 4cm laterally. Trace edema in lower extremities.
Abdomen: Abdomen round, soft, with bowel sounds noted in all four quadrants. No organomegaly noted.
Labs from 3 months ago: