Heart Work Up
Uploaded by
nitenurse718Heart Work Up
Uploaded by
nitenurse718CC: “Heart checkup”
HPI: P.V is a 44-year-old White female with no PMH in the office today for heart
check-up and establish care. Pt stated she noticed palpitations during the pandemic
that started due to increased caffeine intake, and she also notices them a week
before her period starts. She saw her OB/gyn who instructed her to reduce her
caffeine intake and pt stated that has helped. She has not experienced palpitations
in a few months but wanted to have a cardiac work-up for a baseline.
Allergies: Denies allergies to food, medications, or latex.
PMH: None
Past Surgical History: C-section x3, last one 12 years ago
Medications: Multi-vitamin
Health Maintenance: Update with all childhood vaccines
Flu vaccine 2023, Covid Vaccine 2022. Last PCP visit 2 weeks ago. Last eye exam
2023, Dental exam 2023
Family History:
Father, Deceased 66 M.I
Mother, 65: Hx of brain aneurysm at 50
Husband 50 HTN
Sons 12, 15, 16
Social History: Lives with husband and 3 children and is a drug rep
Alcohol: wine socially. Tobacco: denies use of cigarettes, cigars, vape, cannabis.
Drug: denies use
Review of Systems:
General: Denies fatigue, fever, chills, or changes in weight
HEENT- Denies history of headaches, head injuries. Denies wearing glasses,
changes in vision, eye pain, discharge, redness. Denies ringing in the ear, dizziness,
infection or hearing loss. Denies sinuses trouble, nosebleeds, trouble with breathing.
Denies trouble with chewing, swallowing, hoarseness, tooth pain, sore throat, or
bleeding gums. Denies oral sores, nasal discharge, hearing problems.
Neck: Denies pain, lumps, stiffness.
Breast- Denies discharges, tenderness, pain
Respiratory: Denies dyspnea, wheezing, cough
Cardiovascular: denies palpitations, denies chest pain, edema
GI: Denies nausea, vomiting, diarrhea, constipation, pain.
Neurologic: Denies fainting, dizziness, seizures, vertigo, numbness, tremors.
Urinary: Denies frequent urination or burning urination.
Genital: Denies discharge, pelvic pain, STIs.
Peripheral vascular: Denies history of DVT, leg edema, but has B/L leg cramping.
Musculoskeletal: Denies joint stiffness or pain.
Hematologic: Denies easy bruising or bleeding. Endocrine: Denies temperature
intolerance
Psychiatric: Denies history of depression and but has been feeling anxious. Denies
treatment for psychiatric disorders. Denies suicidal or homicidal ideation.
Physical Examination:
Vitals: BP 130/80, HR 60, RR 16, Temp (Oral)-98.9, 02 Sat 98%, Ht- 5’8, Wt- 153lbs,
BMI- 25.5
General: P.V is an pleasant, well-groomed, female, A&O x4 and responds
appropriately during interview. Pt appears calm and pleasant, appears stated age,
is well hydrated and norished.
Skin: Warm to touch, intact and appropriate for ethnicity. Skin feels smooth and
warm. No lesions, bruises, scratches, rashes, or lumps noted. Nails are clean and
well kept. < 2 seconds capillary refill.
Cardiovascular- Listened to the heart at each of the auscultatory areas with the
stethoscope. Listened for abnormal heart sounds or murmurs. Heart rate and
rhythm-normal sinus rhythm. No murmurs, gallops, or rubs are auscultated. S1 and
S2 are heard and are of normal intensity.
Respiratory: No pain on frontal and maxillary sinuses. Chest symmetric, bilateral
fremitus equal & expected. No signs of respiratory distress. Lung sounds are clear in
all lobes bilaterally without rales, rhonchi, or wheezes. Resonance is normal upon
percussion of all lung fields. Negative bronchophony.
Peripheral Vascular: All pulses are present (carotid, brachial, radial, pedal, +2). No
edema noted to legs. No changes in color, varicose veins, rashes, ulcers, scars or
pain noted to legs. JVD is absent. No pain present currently in legs. Checked for
hernias which was negative.
Differential Diagnoses: Follow up visit Z13.9
Plan: Performed Echo, EKG, carotid and arterial doppler in office, which revealed
normal function.
Stress test for diagnostic and prevention and order MCT to r/o Afib
Pt has had a CTA done for prevention d/t family h/o of brain aneurysm which was
normal.
Patient education: MCT and stress test, what to expect. Bring lab work from PCP at
next visit
