Case Study
Chief complaint: “I’m here for a medication refill because I ran out of my medicines”.
HPI: Mrs. Allen is a 68-year-old African American who presents to the clinic for prescription refills. The patient indicates that she has noticed shortness of breath which started about 3 months ago. The SOB gets worse with exertion, especially when she is walking fast, and it is resolved when she is resting. She reports that she is also bothered by shortness of breath that wakes her up intermittently during her sleep. Her symptoms of shortness of breath resolve after sitting upright on 3 pillows. She also has lower leg edema pitting 1+ which started 2 weeks ago. She indicates that she often feels light-headed at times with intermittent syncope episodes while going up a flight of stairs, but it resolves after sitting down to rest. She has not tried any over the counter medications at home.
She started taking her medications but failed to refill the prescriptions because she cannot afford the medications as she only works part-time and lives alone. In addition, she reports that she does not think taking all these medications would help her condition anyway.
PMH: Primary Hypertension, Previous history of MI 1 year ago
Surgeries:
1 year ago-Left Anterior Descending (LAD) cardiac stent placement
Allergies: Penicillin
Vaccination History: Up-to-date
Social history:
High school graduates married and no children. Drinks one 4-ounce glass of red wine daily. She is a former smoker and stopped 5 years ago.
Family history:
Both parents are alive. Father has a history of MI and valvular heart disease; mother alive and cardiac history is unknown. He has one brother who is alive and has a history of MI 5 years ago at age 52.
ROS:
Constitutional: Lightheaded and faint with exertion. Respiratory: Shortness of breath with exertion. + Orthopnea. Cardiovascular: + 2 pitting leg edema for 3 weeks.
Psychiatric: Non-contributory.
Physical examination:
Vital Signs: Height: 5 feet 1 inches Weight: 175 pounds BMI: 32, Obese, BP 160/92, T 98.0, P 111, R 22 and non-labored
HEENT: Normocephalic/Atraumatic, Bilateral cataracts; PERRLA, EOMI; Teeth intact. Negative for gum disease. NECK: Neck supple, no palpable masses, no lymphadenopathy, no thyroid enlargement. LUNGS: + Mild Crackles on inspiratory phase not clearing with cough. Equal breath sounds. Symmetrical respiration. No respiratory distress. HEART: Normal S1 with S2 during expiration. An S4 is noted at the apex; + systolic murmur noted at the right upper sternal border without radiation to the carotids. Pulses are 2+ in upper extremities and 2+ in pedal pulses bilaterally. 2+ pitting edema to her knees noted bilaterally. ABDOMEN: No abdominal distention. Nontender. Bowel sounds + x 4 quadrants. No organomegaly. Normal contour; No palpable masses. GENITOURINARY: No CVA tenderness bilaterally. GU exam deferred. MUSCULOSKELETAL: + Heberden’s nodes at the DIP joints, hands. + Crepitus, bilateral knees. Slow gait but steady. No Kyphosis. PSYCH: Normal affect. Cooperative. SKIN: No rashes. Positive for dry skin.
