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Chest pain and difficulty breathing
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History of Present Illness and Hospital Course
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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.
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Mother: had two heart attacks and died of heart failure at age 73
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Father: had hypertension and died at age 79 after an MI
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The patient lives with her daughter, using a walker to ambulate through her home.
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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.
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Patient is Spanish speaking.
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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
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Inpatient Medications
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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
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BP 128/78 mmHg, P 72; RR 16; Temp 98.8°F; Ht: 61″, Wt: 95 kg
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Obese Hispanic female, resting comfortably, A&O × 4.
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Normocephalic, PERRLA, mild JVD, supple, no lymphadenopathy.
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