Name: W.L.

Date : 3/8/2019 Time : 100

DOB: 12/24/1958 Sex: M
Subjective
CC: Chest pain & dyspnea with exertion, bilateral leg swelling

HPI: W.L. is a 60-year-old male who presents to MGL ED with chest pressure and dyspnea. He
states that over the last few days he has had increasing chest pressure & dyspnea with exertion.
He also endorses dizziness with position changes. Outside of rest, he denies any exacerbating
or alleviating factors. Feels that bilateral legs are swollen from the feet to the groin.

Patient has missed two most recent cardiology appointments citing transport issues. Denies
having a pulmonary provider. Wears CPAP at night, current smoker, consumes ½ pack a day
for the past 40 years. Is not prescribed home oxygen.

Medications:
Aspirin 325mg, PO, daily
Bumex, 1mg, PO, BID
Coreg: 3.125mg, PO, BID
Insulin detemir, 50 units, subcutaneous, QPM
Levothyroxine 200mcg, PO, daily
Lingaliptin 5mg, PO, daily
novoLOG, 18 units, subcutaneous, QID 9w/meals)
Plavix, 7mg, PO, daily
Potassium chloride 20mEq, PO, TID
Prozac, 40mg, PO, daily
Ropinirole: 0.25mg, PO, daily
Spiriva, 18mcg, inhalation, daily
Symbicort, 160mc-4.5mcg/inh, inhalation, BID
Ventolin, 2.5mg, inhalation solution, Q4H, PRN
Wellbutrin SR 150mg, PO, QAM

Allergies:
Lisinopril: tongue swelling, swelling of throat
Penicillin: redness, itching, rash
PMI
Illnesses/Injuries
Childhood: Not assessed
Adult- HFrEF (10-20%), s/p ICD, COPD, HTN, CAD s/p 4 stents, IDDM, type 2.
Hospitalizations/Surgeries:
Influenza- Not received Pneumovac- Unknown Tetanus- (TdaP) Unknown
Last colonoscopy - Unknown
FH:
Mother: Dementia (unspecified)
Father: Heart disease, CVA

SH: Patient lives with spouse. Three adult children live locally. Per W.L., all three have
substance abuse problems, have stolen property

Tobacco: Never smoker ETOH: “maybe once a month. I only drink like, a beer”. Elicit drugs:
denies
ROS

General:
Pt states “I’ve just been really down lately
and I didn’t realize how bad it was until I got
to this point. I thought maybe it was just
because I was having a hard time with my
grandfather passing away but looking back,
it’s been getting worse for about 4 months.
All I do is sleep. As soon as I get home from
work until the moment I go in. I don’t even
want to take showers.”
Skin:
Patient denies any rash, wounds, history of
skin disorders, changes in moles, pruritis,
lesions, burns.
Eyes:
The patient denies blurry vision, itching,
vision changes. Pt wears glasses
Ears:
Pt denies ear pain, hearing loss, discharge.
Denies changes in hearing, vertigo, or
tinnitus.
Cardiovascular:
Pt denies CP, palpitations, orthopnea,
paroxysmal nocturnal dyspnea, or murmurs,
dizziness, SOB.
Respiratory:
Patient denies cough, wheezing, dyspnea or
shortness of breath.
Gastrointestinal:
Pt denies abdominal pain, nausea/vomiting.
Denies constipation, diarrhea, or acid reflux.
Normal bowel pattern. States decreased
appetite.
Genitourinary/Gynecological:
Patient denies urinary retention, pain, burning,
decreased output or foul odor. She denies
vaginal itching, irritation or discharge.

Nose/Mouth/Throat:
Pt denies rhinorrhea/congestion, stuffiness,
sneezing. Denies itching, epistaxis, or sinus
pressure. Denies bleeding gums, hoarseness,
swollen lymph nodes, or oral lesions. Denies
odynophagia.
Breast:
Pt denies pain, swelling, leakage, tenderness
or lumps.
Musculoskeletal:
Pt complains of geneleralized musculoskeletal
pain, weakness.
Neurological:
Pt denies dizziness, LOC, numbness. Denies
loss of sensation, tingling, headache, or
 seizures.

Objective

Wt: 172 lbs Temp: 98.0 Pulse: 78

Ht: 5’3” BP: 122/72 Resp: 16

Physical Exam

General Appearance: Alert, oriented, morbidly obese, no acute distress, poorly groomed.

Skin: Skin is warm, dry and pink, no rashes or lesions.

HEENT: Normocephalic, atraumatic, nose midline

Cardiovascular: PMI is non-displaced, brisk and tapping, diameter 2 cm. Regular rate and
rhythm, pulse rate of 78, S1 and S2 present, no murmurs, rubs, gallops, clinics, precordial
movements. Pulses 2+ and equal bilaterally in upper extremities and lower extremities without
thrills. No temporal, carotid, abdominal aorta, femoral, iliac, or renal bruits. No JVD. Capillary
refill < 3 seconds. 2+ pulses bilaterally. No edema noted.

Respiratory: Chest is symmetrical with respirations. Respirations even and unlabored, no

accessory muscle use noted. Lungs clear to auscultation in all fields. Pulse ox 100% on RA.

No pain with percussion or palpation. No rebound tenderness noted. Positive bowel sounds in
all four quadrants. Percussion reveals dullness over spleen and liver. Unable to palpate spleen.
Lower quadrant of liver palpable. Abdomen is soft, tender, non-distended.

Genitourinary: No bladder distention. External genitalia normal. No gross lesions. Vagina

shows healthy pink mucosa. Kidneys palpated.

Musculoskeletal: Bilateral upper extremities without muscle atrophy or joint deformity. Normal
ROM, joint stability normal in all extremities, no tenderness to palpation. No scoliosis noted.
Normal strength, tone. Steady gait. Bilateral upper extremities with full range of motion of
shoulder, elbow, and wrist. Full range of motion of bilateral hips, spine with some obvious
discomfort. Bilateral upper extremity strength equal and 5/5 in neck, legs , shoulders, elbows,
wrists, hands.

Neurological: Facial sensation intact; facial features and symmetric. Gag reflex intact. Ability
to shrug shoulders symmetric; 5 strength against resistance. Neck with full range of motion
against resistance; 5 strength against resistance. Tongue symmetric with no abnormal findings..
Point-to-point movements smooth and accurate for finger-to-nose and heel-to-shin. Rapid
alternating movements of the upper and lower extremities intact bilaterally. Sensation intact to
bilateral upper and lower extremities; sense of extremity position intact. Pt alert and oriented to
person, place and time.

Lab/Special Test: Urine pregnancy,TSH

Assessment

Differential Diagnosis: Hypothyroidism E 03.9, Pregnancy Z34.00, Other fatigue R53.83

Grief Z63.4

Diagnosis: Major Depressive Disorder F32.9, Body mass index (BMI) 37.0-37.9, adult.
Z68.37

Plan

Plan: The plan is to gradually dual taper over the next four weeks by reducing the dosage and
frequency of the Lexapro and switching over to Effexor. Pt to see Behavioral Health as
scheduled, follow up in 3 weeks to discuss medication effectiveness.

Teaching: Patient educated on withdrawal symptoms. She is told about the “black box
warning” and to immediately stop the medication and go to the Emergency Department if she
has any suicidal or homicidal thoughts. Pt is taught about health promotion techniques such
as exercise and healthy eating to help with symptoms of depression.