Year Two: Patient Bedside Write-up #1

Aleks Penev
9/16/2014
Ms. C is a 51 year old female who presented to clinic with shortness of breath and
chest pain starting 4 days prior.
HPI: Patient first presented in February of this year with appendicitis following 35
years without seeing a physician, when blood-work revealed chronic anemia and
late-stage kidney failure. Patient admitted to a long-standing history of untreated
hypertension. She was subsequently put on amlodipine to control her hypertension
and underwent follow-up care for her kidney disease, including kidney biopsy 1
month ago which indicated either diabetic or hypertensive microvascular changes
according to different physicians opinions. She was started on dialysis until she
could receive a kidney transplant. In the last year, she noticed that she would have
severe muscle spasms in her arms and fingers that would abate with time. Patient
also complained of fainting spells when standing up and chills starting in May, and
subsequently underwent a nuclear stress test two weeks ago. During the test, it was
revealed that she had stopped her amlodipine because it was making her ill when
her BP was 206/95. She was given a beta-blocker before the test proceeded and
suffered a strong reaction to the dye, including nausea, dizziness, and a severe
blood-pressure drop to 100 systolic. Following the stress test, patient was started on
labetolol and reported that she felt extreme fatigue for 3 days afterwards and felt a
dull chest pain described as similar to a muscle ache starting 4 days prior to
admission. The pain did not occur at rest and began to be accompanied by
shortness of breath on exertion starting 2 days ago. The patient reports that on two
different occasions she was unable to climb more than a flight of stairs without
needing to stop due to her SOB. She was admitted to the ER after describing these
symptoms to her vascular physician during her dialysis consultation, where they
discovered she was severely anemic and had mild edema.
PMH: Due to her long history without medical check-ups, her previous history is
relatively scarce. Patient described headaches and fainting spells in her childhood
and recent past. After her appendicitis surgery, an ophthalmologist diagnosed her
with diabetic vascular damage in her eyes, but she has never been diagnosed with
diabetes, never took any medication for it, and has no blood-evidence of diabetes
currently. She has a history of very heavy periods all her life, which have become
very irregular these past few years, with an almost 3 month gap between her two
most recent periods, the most recent of which occurred immediately after her
stress-test.
Meds/Allergies: Patient was started on Lasics 40mg, labetolol 200mg, and baby
aspirin upon admission to the ER. Patient denies any allergies besides a suspicion
that she might have a "fresh-mushroom" allergy.

FH: Mother was very ill all her life with diabetes and heart and kidney disease
requiring coumadin prior to death of MI at 62. Maternal grandmother also died of
heart problems related to HTN. Father was a smoker all his life, diagnosed with
vascular illness and HTN and underwent 3 vascular surgeries to his heart and
diagnosed with kidney disease after the 2nd surgery. Pt's two brothers are living,
one has a history of diabetes and was recently diagnosed with stage 3 kidney
disease, the other has a long history of substance abuse and has been out of
contact with family for a while.
SH: Patient is unmarried and has no children. She lives with a roommate in Jersey
City and has not been sexually active for some time. She reported having tested
negative for "the usual" STI's on one of her hospital visits. Used to work as a nanny
and housekeeper for 28 years until May when her diagnoses made her quit and
begin training as a yoga instructor. Patient denies smoking and drinking aside from
a glass of wine every 6 months.
ROS: Patient mentioned that one of her physicians had found evidence of ANA
antibodies in her blood and she complains of joint pain and stiffness. A different
physician had told her there was evidence of Lyme disease in her bloodwork.
PE: PT was well-developed, well-nourished, in no apparent distress and appeared
stated age.
Vitals were HR 72 and RR 18.
Cardiac exam revealed regular rate and rhythm and revealed no rubs, thrills or
murmurs and a strong radial pulse.
Pulmonary ascultation showed normal breath sounds with no crackles or rhonchi.
Abdominal exam showed normal bowel sounds and absence of renal bruits or
tenderness in the abdomen. A small scar was noticeable on exam.
Extremity exam showed normally pigmented and perfused skin with normal
capillary refill. No redness or swelling was evident in joints of hand. No appreciable
edema in her legs.
Assessment:
SOB, chest pain, and faintness likely due to uncontrolled anemia secondary to
kidney failure. Heart failure seems unlikely due to absence of crackles or edema at
time of exam.