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PATIENT PRESENTATION

Chief Complaint

Chest pain and difficulty breathing

History of Present Illness and Hospital Course

RE is a 70-year-old Hispanic female who has been treated for atrial fibrillation (AF) with rapid ventricular response (RVR). She was initially brought in by ambulance for chest pain and shortness of breath. After a myocardial infarction (MI) was ruled out, she was treated for AF with RVR. She is recovering on the telemetry floor and the medical team is planning to discharge her later today. She has trouble with keeping her INR within range and she complains about needing to get too many labs.

Past Medical History

Hypertension

Type 2 diabetes

Heart failure

Atrial fibrillation

Stroke 2 years ago

Surgical History

Hysterectomy

Family History

Mother: had two heart attacks and died of heart failure at age 73

Father: had hypertension and died at age 79 after an MI

Social History

The patient lives with her daughter, using a walker to ambulate through her home.

She denies smoking for the past 20 years but used to smoke 1 pack per day × 25 years prior to that. She denies any alcohol use.

Patient is Spanish speaking.

Allergies

No known drug allergies

Immunization

Up to date

Insurance

Aetna Medicare Advantage

Home Medications

  • Metformin XR 750 mg PO bid

  • Insulin glargine U-100 SC 28 units nightly

  • Lisinopril 5 mg PO daily

  • Atenolol 25 mg PO daily

  • Furosemide 20 mg PO daily

  • Warfarin 4 mg PO MWF, 2 mg PO Tu/Th/Sat/Sun

  • MVI 1 tab PO daily

  • NTG 0.4 mg SL PRN chest pain

Inpatient Medications

  • Insulin lispro SC sliding scale

  • Warfarin 4 mg PO MWF, 2 mg PO Tu/Th/Sat/Sun

  • Furosemide 40 mg PO daily

  • Lisinopril 5 mg PO daily

  • Metoprolol tartrate 25 mg PO bid

  • Atorvastatin 20 mg PO daily

  • MVI, 1 tab PO daily

  • NTG 0.4 mg SL PRN chest pain

  • Docusate sodium 100 mg PO twice daily PRN for constipation

Physical Examination

Vital Signs

BP 128/78 mmHg, P 72; RR 16; Temp 98.8°F; Ht: 61″, Wt: 95 kg

General

Obese Hispanic female, resting comfortably, A&O × 4.

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