History

 

Identifying Data:

Full Name: KS

Address: Aspen, CO

Date & Time: November 27, 2018 9:20 AM

Location: New York Presbyterian Queens

Religion: Unknown

Source of Information: Self, Reliability Good

Source of Referral: EMS

Mode of Transport: Ambulance

 

Chief Complaint: “I fainted twice at the airport”

 

History of Present Illness:

64 y/o male, with PMHx of HTN, and hyperlipidemia, presents to Emergency Room after two syncopal episodes at the airport. Pt was brought in by EMS and states he does not remember much except that he was waiting for his plane and that airport personnel informed him that he fainted twice lasting only a few minutes. Pt also currently complains of right-sided chest pain on inspiration that started during transport and it comes and goes and describes it as pressure. Pain does not radiate and nothing has alleviated or exacerbated it. Pt states the pain is a 1 out of 10, and that he has not fainted or had chest pain before. Pt also admits to generalized weakness/fatigue, and recently being diagnosed with a right bundle branch block. Pt denies any other trauma, recent weight loss or gain, loss of appetite, fever or chills, night sweats, headache, vertigo, head trauma, SOB/DOE, cough, wheezing, hemoptysis, PND, cyanosis, or orthopnea. Pt denies palpitations, irregular heartbeat, edema, heart murmurs, seizures, sensory disturbances, ataxia, loss of strength, change in cognition/mental status/memory, intermittent claudication, coldness or trophic changes, varicose veins, peripheral edema, blood clots, cramping in legs, ulceration of extremities, hair loss or color change. He also denies any polyuria, polydipsia, polyphagia, goiter or tremors.

 

Past Medical History:

HTN x 6 months

Hyperlipidemia x 6 years

Childhood illnesses – Denies

Immunizations – Up to date; flu vaccine yearly.

Screening tests and results: Denies PPD recently, EKG done on August 2018 results unknown, Cardiac Catheterization on August 2018, results indicate a right bundle branch block

 

Past Surgical History:

Denies any surgeries.

 

Medications:

Amlodipine, 5 mg PO daily for HTN, last dose this morning

Lisinopril, 10mg PO daily for HTN, last dose this morning

Hydrochlorothiazide, 12.5 mg PO daily for HTN, last dose this morning

Simvastatin, 40 mg PO daily for Hyperlipidemia, last dose two nights ago

Denies herbal vitamin and supplement use

 

Allergies:

Denies any allergies. Denies other drug, environmental or food allergies.

 

Family History:

Mother – Deceased at age 86, natural causes

Father – Deceased at age 65, Colon Cancer

Maternal grandfather – Deceased at age 71, MI

Maternal grandmother – Deceased at age 85, unknown cause

Paternal grandmother – Deceased at age 84, natural causes

Paternal grandfather – Deceased at age 90, natural causes

Uncle – Deceased at age 68, Pancreatic cancer

 

Social History:

Mr. S is a married male, living with his wife of 22 years. He works as an entrepreneur.

Habits – He denies any past/present alcohol use or caffeine. He denies any past/present smoking or illicit drug use.

Travel – Travels to Aspen, CO and New York, NY and other areas a fair amount for work.

Diet – He states his diet is not great, eats out for lunch and likes sweets.

Exercise – He denies any formal exercise, sleeps, about 4-5 hours each night.

Safety measures – Admits to wearing a seat belt, using a helmet, has smoke detectors in home, and uses sunscreen when outdoors.

Sexual Hx – Heterosexual, states he is currently sexually active and has one partner, wife. He is intimate with females in oral and vaginal intercourse. Denies using contraception and history of sexually transmitted infections.

 

Review of Systems:

General – See HPI.

 

Skin, hair, nails – Denies changes in texture, excessive dryness, oiliness, or sweating, discolorations, pigmentations, moles/rashes, pruritus, lesions, easy bruising, or changes in hair distribution.

 

Head – See HPI.

 

Eyes –Denies any blurry vision, diplopia, scotoma, halos, infection, pain, discharge, injury, lacrimation, photophobia, or pruritus. He wears contacts. Last eye exam April 2018 – states his visual acuity is 20/20 with normal pressure.

 

Ears – Denies any deafness, decrease hearing, pain, discharge, tinnitus, infection, and use of hearing aids.

 

Nose/sinuses – Denies any discharge, epistaxis, obstruction, unusual odors, sinus infections, pain, injury, frequent sneezing, or loss of smell.

 

Mouth/throat – Denies bleeding gums, sore throat, excessive salivation or dryness, discharge, lesions, change in taste or texture, sore tongue, mouth ulcers, dysphagia, voice changes, loss of/trouble speaking or use of dentures. Last dental exam October 2018, unremarkable.

 

Neck – Denies localized swelling/lumps, pain, or stiffness/decreased range of motion, or soreness.

 

Breast – Denies any lumps, nipple discharge, tenderness, masses, deformity, changes in nipple or skin, or pain.

 

Pulmonary system – See HPI. TB skin testing in 2017 was negative.

 

Cardiovascular system – See HPI. Last EKG was September 2018, results unknown, and Cardiac Catheterization in September 2018, results indicate a right bundle branch block.

 

Gastrointestinal system – He has regular bowel movements daily. Denies change in appetite, intolerance to specific foods, nausea, vomiting, hemoptysis, pyrosis, unusual flatulence or eructations, abdominal pain, diarrhea, jaundice, hemorrhoids, constipation, rectal bleeding, or blood in stool.

 

Genitourinary system – Denies urinary frequency or urgency, nocturia, oliguria, polyuria, dysuria, incontinence, kidney stones, or lumbar/flank pain

 

Nervous system – See HPI.

 

Musculoskeletal system – Denies muscle/joint pain, limitation of motion, deformity or swelling, gout, neck pain, herniated disc, redness or arthritis.

 

Peripheral vascular system – See HPI.

 

Hematological system – Denies anemia, easy bruising or bleeding, lymph node enlargement, blood transfusions, or history of DVT/PE.

 

Endocrine system – See HPI. Denies excessive sweating and hirtuism.

 

Psychiatric – Denies insomnia, excessive sleep or sleep disturbances, disorientation, mood extremes, hallucinations, delusions, depression/sadness, anxiety, OCD or seeing a mental health professional.

 

 

Physical

 

General: Well developed male, neatly groomed in no apparent distress. Alert and cooperative, looks younger than his stated age of 64.

 

Vital Signs:    BP:                              R                     L

Seated

Supine             100/60

 

R:        16 breath/min, unlabored                    P:        84 beats/min, regular

 

T:        98.6 degrees F (oral)               O2 Sat: 98% Room air

 

Height: 66 inches   Weight: 172 lbs.   BMI: 27.8

 

Skin:   warm & moist, good turgor. Nonicteric, no lesions noted, no scars, tattoos.

Hair:   average quantity and distribution.

Nails: no clubbing, capillary refill <2 seconds throughout.

Head: normocephalic, atraumatic, non tender to palpation throughout

 

Eyes: symmetrical OU; no evidence of strabismus, exophthalmos or ptosis; sclera white;

conjunctiva pink & cornea clear.

Visual acuity (Corrected – 20/20 OS, 20/20 OD, 20/20 OU).

Visual fields full OU.   PERRLA, EOMs full with no nystagmus

Fundoscopy – Red Reflex intact OU, Cup: Disk <= 0.5 OU, no evidence of copper wiring, A-V nicking, cotton wool spots, papilledema, hemorrhage, exudate, or neovascularization.

 

Ears: Symmetrical and unremarkable size. No evidence of lesions/masses/trauma on external ear. No discharge/foreign bodies in external auditory canals AU. TM’s pearly white/ intact with light reflex in normal position AU. Auditory acuity intact to whisper test AU. Weber midline/ Rinne reveals AC>BC AU.

 

Nose and Sinus Exam: Nose symmetrical, no obvious masses, lesions, deformities, trauma, discharge. Nares patent bilaterally, nasal mucosa pink and well hydrated. No discharge noted on anterior rhinoscopy. Septum midline without lesions, deformities, injection, or perforation. No evidence of foreign bodies.

Sinuses: Non tender to palpation over bilateral frontal and maxillary sinuses.

 

Neck: Trachea midline. No masses, lesions, scars, pulsations noted. Supple, non-tender to palpation. FROM, no stridor noted. No thrills, bruits noted bilaterally, no palpable adenopathy noted.

 

Thyroid: Non-tender, no palpable masses, no thyromegaly, no bruits noted.

 

Chest –     Symmetrical, no deformities, no evidence trauma.   Respirations unlabored / no paradoxic respirations or use of accessory muscles noted. Lat to AP diameter 2:1.   Non-tender to palpation.

 

Lungs –   Clear to auscultation and percussion bilaterally.   Chest expansion and diaphragmatic excursion symmetrical.   Tactile fremitus intact throughout. No adventitious sounds.

 

Heart:  JVP is 2.5 cm above the sternal angle with the head of the bed at 30°. PMI in 5^th ICS in mid-clavicular line.  Carotid pulses are 2+ bilaterally without bruits. Regular rate and rhythm (RRR); S1 and S2 are normal. There are no murmurs, S3, S4, splitting of heart sounds, friction rubs or other extra sounds.

 

 

Assessment:

64 y/o male with HTN, right bundle branch block, and hyperlipidemia to be evaluated for syncopal episodes and chest pain. Rule out Acute Coronary Syndrome.

 

Differential Dx:

Orthostatic Hypotension

Vasovagal syncope

Head Bleed

Pulmonary Embolism

Stokes-Adams Syndrome

 

Plan:

• Syncope: Order CBC, Chem-7, UA, Head CT.
• Chest pain: with Inspiration without SOB. Cardiac workup, Order EKG, cardiac markers, Troponin, and D-Dimer. Admit to hospital for cardiac monitoring.