Palpitations Other and unspecified hyperlipidemia Unspecified essential hypertension Pure hypercholesterolemia
 
Name:  ___                    Unit No:   ___
 
Admission Date:  ___              Discharge Date:   ___
 
Date of Birth:  ___             Sex:   F
 
Service: MEDICINE
 
Allergies: 
Patient recorded as having No Known Allergies to Drugs
 
Attending: ___.
 
Chief Complaint:
Palpitations
 
Major Surgical or Invasive Procedure:
none

 
History of Present Illness:
HPI: The patient is a ___ year-old female with a history of 
episodic cardiac arrhythmia, hypertension, and hyperlipidemia, 
who presents for heart palpitations.  Mrs. ___ was in her 
usual state of good health until 9am on the day of admission, 
when she experienced a "surging sensation" in her chest, with 
rapid heart rate, and a constant, dull ___ discomfort near her 
sternal angle, radiating to the ___ her back.  She reports 
that the episode began while she was leaning over her sink, 
lasted ___ hours, and ended spontaneously.  She reports a 
sensation of fatigue which began coincident with the cessation 
of palpitations.  Mrs. ___ denies diaphoresis, dizziness, 
syncope, or shortness of breath (the patient can walk up 3 
flights of stairs without dyspnea).  She reports no recent 
fevers/chills or nausea/vomiting.  The patient has experienced 
___ previous episodes of arrhythmia over the past ___ years (most 
recent was 6 months ago), with chest discomfort and heart rate 
elevation similar to the current episode, leading to one 
previous hospitalization.  The cardiac history is otherwise 
negative.  During this episode, Mrs. ___ called EMS, and was 
brought by ambulance to ___.  
.
In the ED, Mrs. ___ was asymptomatic, with T 97.3, P 54, BP 
115/54, RR 18, and SaO2 95 on RA.  An EKG was obtained, showing 
normal sinus rhythm and no signs of ischemia.  Cardiac troponin 
level in the ED was 0.02, UA was negative, and CXR was normal.  
ASA (325 mg) was given, and Mrs. ___ was transferred to the 
floor for observation and further cardiac evalutation.  

 
Past Medical History:
Past Medical History:
     1. Episodic cardiac arrhythmia (The first episode of 
     tachycardia/palpitations occurred a few years ago, and 
lasted 
     for 1 hour, resulting in an admission to ___ in 
     3 additional episodes have occurred since this point.  The 
most 
     recent episode was 6 months ago, prompting evaluation by a 
     cardiologist [Dr. ___, including echocardiogram and home 
     telemetry, with normal results).  
     2. Hypertension
     3. Hypercholesterolemia
     4. Elevated calcium level (measured at 10.3 2 weeks ago)
     5. Irritable bowel syndrome (periodic diarrhea)
     6. Back pain

 
Social History:
___
Family History:
Family History:
     Patient's Father: coronary artery disease (died at age ___
     Patient's Mother: heart valve dysfunction (specifics 
unknown)
     Patient's Daughter: parathyroid gland removed

 
Physical Exam:
PE:  Vitals  T 97.9  P 58  BP 125/67  RR 20  SaO2 99 (RA)
.
General: This is a healthy-appearing female, nontoxic appearing. 
 On exam, she was conversational and in no apparent distress.  
Skin: Warm and well perfused, with good color.  Nails without 
clubbing or cyanosis.  No rash/petechiae/ecchymoses.  
HEENT: Head is normocephalic and aturaumatic.  Sclera anicteric, 
conjunctiva pink.  Oral mucosa pink, with good dentition 
(multiple metal fillings).  Pharynx without exudates.  Trachea 
midline.  Neck supple.  
Pulmonary: Thorax is symmetric with good expansion.  Chest clear 
to ascultation bilaterally.  No rales/wheezes/rhonchi.
Cardiac: Regular rate and rhythm.  Nml. S1, S2.  No 
murmurs/rubs/gallops.  
Lymphatic: No cervical or supraclavicular lymphadenopathy.  
GI: +Bowel sounds, abdomen soft, nontender, nondistended.  No 
organomegaly.  
GU: Pelvic exam not performed
Rectal: Rectal exam not performed
Neuro:  PEERLA, EOMI, TML, face symmetric, moving ___.
Extremities: Warm and well perfused, radial pulse 2+, DP 2+ 
bilaterally.  Mild tenderness to palpation over left ankle.

 
Pertinent Results:
Imaging:  
CXR-- No evidence of acute intrathoracic process. 
.     
(___) ___ Echocardiogram Reports: The left atrium is 
normal in size. Left ventricular wall thickness, cavity size and 
regional/global systolic function are normal (LVEF >55%) There 
is no ventricular septal defect. Right ventricular chamber size 
and free wall motion are normal. The aortic valve leaflets (3) 
appear structurally normal with good leaflet excursion and no 
aortic regurgitation. The mitral valve leaflets are mildly 
thickened. There is no mitral valve prolapse. Trivial mitral 
regurgitation is seen. The estimated pulmonary artery systolic 
pressure is normal. There is no pericardial effusion. 
IMPRESSION: Normal global and regional biventricular systolic 
function. No pulmonary hypertension or significant valvular 
disease seen. 

___ 10:15PM   CK(CPK)-59
___ 10:15PM   CK-MB-NotDone cTropnT-0.05*
___ 11:55AM   GLUCOSE-106* UREA N-15 CREAT-1.0 SODIUM-142 
POTASSIUM-3.7 CHLORIDE-100 TOTAL CO2-33* ANION GAP-13
___ 11:55AM   estGFR-Using this
___ 11:55AM   CK(CPK)-55
___ 11:55AM   cTropnT-0.02*
___ 11:55AM   CK-MB-NotDone
___ 11:55AM   CALCIUM-10.2 PHOSPHATE-3.3 MAGNESIUM-2.2
___ 11:55AM   WBC-4.9 RBC-4.49 HGB-15.0 HCT-41.4 MCV-92 
MCH-33.3* MCHC-36.1* RDW-13.7
___ 11:55AM   NEUTS-50.1 LYMPHS-43.9* MONOS-4.4 EOS-1.0 
BASOS-0.6
___ 11:55AM   PLT COUNT-254
___ 11:30AM URINE  HOURS-RANDOM
___ 11:30AM URINE  GR HOLD-HOLD
___ 11:30AM URINE  COLOR-Straw APPEAR-Clear SP ___
___ 11:30AM URINE  BLOOD-TR NITRITE-NEG PROTEIN-NEG 
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-8.0 
LEUK-NEG
___ 11:30AM URINE  ___ WBC-0 BACTERIA-NONE YEAST-NONE 
EPI-<1 TRANS EPI-1
 
Brief Hospital Course:
This is a ___ year-old female who presents with chest discomfort 
and palpitations.  
.
# To address heart palpitations, the patient was put on 
continuous monitoring with Telemetry.  Electrolytes were 
monitored frequently, and cardiac enzymes were checked q8hrs.  
Aspirin was given (81 mg, PO, Qdaily), and the patient was 
arranged for further ambulatory event monitoring with her 
cardiologist (Dr. ___, and outpatient follow-up.  
.
# To address irritable bowel syndrome, home med Sucralfate 1gm 
daily was given
.
# To address the patient's hypertension, home med felodipine 
(2.5 mg, PO, Qdaily) was given.
.
# To address hypercholestrolemia, atorvastatin (20 mg, PO, 
Qdaily) was given.
.
# To address fluids/electrolytes/nutrition, the patient was 
given a regular diet, and electrolytes were repleted PRN 
(optimizing to mag 2.5 and K of 4.5).
.
# For DVT Prophylaxis, the patient was given Sub-cutaneous 
heparin.
 
Medications on Admission:
     1. Bisoprolol-HCTZ (5mg-6.25 mg, PO, Qdaily)
     2. Lovastatin (20 mg, PO, Qdaily)
     3. Sucralfate (1 g, PO, Qdaily)
     4. Felodipine SR (2.5 mg, PO, Qdaily)
     5. Aspirin (81 mg, PO, Qdaily)
     6. Acidophilus (1 capsule, PO, Qdaily)
     7. Vitamin C (1 capsule, PO, Qdaily)
     8. Multivitamin (1 tab, PO, Qdaily)
 
Discharge Medications:
1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable 
PO DAILY (Daily).  
2. Sucralfate 1 gram Tablet Sig: One (1) Tablet PO DAILY 
(Daily).  
3. Felodipine 2.5 mg Tablet Sustained Release 24 hr Sig: One (1) 
Tablet Sustained Release 24 hr PO DAILY (Daily).  

 
Discharge Disposition:
Home
 
Discharge Diagnosis:
Palpitations

 
Discharge Condition:
Good

 
Discharge Instructions:
Return to the ED immediately if you experience 
- shortness of breath
- heart palpitations
- chest pain
- loss of conciousness
 
Followup Instructions:
___

{'surging sensation': ['Palpitations'], 'rapid heart rate': ['Palpitations'], 'dull discomfort near sternal angle': ['Palpitations'], 'radiating to the back': ['Palpitations'], 'fatigue': ['Palpitations'], 'diaphoresis': [], 'dizziness': [], 'syncope': [], 'shortness of breath': [], 'fevers/chills': [], 'nausea/vomiting': [], 'elevated calcium level': ['Pure hypercholesterolemia'], 'irritable bowel syndrome': [], 'back pain': []}