Case 2
Case # 2 Kristy Nyugen
Chief Complaint: A 30 year old Vietnamese female presents with palpitations
History of Chief Complaint: The patient presents to the outpatient office after her husband insisted
that she get checked out. About a year ago, she first noticed that her heart felt like it was racing. It
comes and goes and it has started to make her feel anxious. She notices that its worse when she tries to
exercise, and she doesn’t recall ever feeling it when she is relaxed. Sometimes she also feels it in the
morning at work. She notes that the palpitations last a few seconds then go away. It is associated with
mild chest discomfort 2/10 dull pain that is also intermittent and is only there when her heart is racing.
She doesn’t think it’s a big deal since it has only happened once or twice in the past few months.
Her husband insisted that she sees a doctor since she hasn’t seen one in over five years and he was
concerned about the chest discomfort.
PMH: No medical problems in the past; no surgeries no; hospitalizations or childhood illnesses
Meds: multivitamin
Allergies: no known allergies
Social History: Has an occasional glass of wine, does not smoke tobacco, denies illicit drug use, eats a
balanced diet; has 2 cups of coffee before work every morning. She works as an administrator at a local
jail.
Family hx: father is 61 and in good health; mother is 65 has htn; dm2, and coronary artery disease; pt
has one sibling that is an alcoholic and has no other health problems
ROS: She denies any headaches or blurry vision, she does feel lightheaded at times if she doesn’t drink
enough water when before she goes to the gym. She denies numbness or tingling anywhere. No hot or
cold intolerance, no easy bruising or bleeding, No cough or orthopnea. No abdominal pain, changes in
bowel habits, or food intolerance. No burning on urination or increased frequency. No joint or hip pains.
No rashes.
Case 2
PE: VS Pulse: 90 R: 10 BP: 140/90 T: 37.2C Pulse Ox: 98% on Room Air
General: Pt is a thin well appearing women, well put together in no acute distress
HEENT: head atraumatic, ears no erythema in tympanic membrane, eyes clear without injection or
discharge, nose without septal deviation, throat without pharyngeal erythema or noticeable defects of
the shape of the airway
Lungs: clear to auscultation bilaterally, no stridor (Stridor is an abnormal, high-pitched sound produced
by turbulent airflow through a partially obstructed airway at the level of the supraglottis, glottis,
subglottis, and/or trachea.), air moves well, good respiratory effort, resonant to percussion
CV: reveals irregular radial pulses, heart with an irregular rhythm and regular rate, left parasternal
heave(praecordial impulse that may be palpable in patients with heart disease. A parasternal impulse
may be felt when the heel of the hand is rested just to the left of the sternum with the fingers lifted
slightly off the chest. Normally no impulse or a slight inward impulse is felt. In cases of right ventricular
enlargement or severe left atrial enlargement, where the right ventricle is pushed anteriorly, the heel of
the hand is lifted off the chest wall with each systole. Palpation with the fingers over the pulmonary area
may reveal the palpable tap of pulmonary valve closure (palpable P2) in cases of pulmonary
hypertension) noted, Grade III crescendo decrescendo murmur heard best in the second intercostals
space to the left of the sternum, and an S2 that is widely split and fixed with respiration.
Abdomen: soft, flat, no masses, no tenderness, bowel sounds in every quadrant.
GU: deferred
Extremities: no cyanosis, no clubbing, no signs of microemboli, trace lower extremity edema while
standing.
Osteopathic: thoracic vertebrate T3 and T4 flexed sidebent right rotated left
Skin: no rashes or other lesions noted