William Byrd, RN, FNP Student 10/9/2013, 10:00 59 Y/O Hispanic Female Patient Subjective Chief Complaint: I fainted

and had shortness of breath. History of Present Illness: This is a 59 year old Hispanic female patient who experienced an episode of fainting and shortness of breath on the past Saturday (4 days ago). She states that she was going out to do yard work at approximately 1PM on Saturday afternoon. She had not actually done any work yet when she says that she started feeling chest pain, lightheaded, short of breath, weak, and felt her heart racing. She also states that she had some numbness and tingling in her left arm. She states that her memory of exactly what happened is blurry and is unsure of what exactly happened. She thinks that her son either helped her to the ground or helped her inside. She does not think she fell to the ground when this happened. She is unsure about loss of consciousness during the episode. Her children did not call 911 or take her to the emergency room. Once she became more oriented, she did not choose to go to the emergency room due to her uninsured status. She states that she continued to have the shortness of breath, chest pain, rapid heartbeat for the rest of the evening, but rested on the couch for the rest of the day. She says that she felt almost normal on Sunday morning when she woke up, but she did still feel a little weak. She states that since Saturdays episode, she has limited her activities and essentially just rested on the couch. She denied any changes to her normal routing prior to the episode on Saturday. She states that she does not think that she was dehydrated. She had eaten lunch prior to the episode. Today in clinic, she states that she feels back to her normal health status, but is concerned about the episode on Saturday. She states that she is worried about the cost of todays visit and the costs associated with a workup. This is this patients first visit to this clinic. Current Health Staus Allergies: No Known Drug Allergies Medications: None Immunization Status: Patient states that she thinks her childhood immunizations are up to date. She is unsure of adult vaccinations. She thinks she has an immunization record at home. Habits: Denies current alcohol, drugs, tobacco, and caffeine. She has a 20 pack year history of smoking, but quit 13 years ago. Health Maintenance Practices: Last Physical exam-Uncertain, thinks was about 8-10 years ago. Last PapUncertain, thinks about 8-10 years ago. Mammogram-Uncertain, thinks was about 8-10 years ago. States that due to lack of insurance, her health visits are limited.

Self Exams: Patient states she occasionally examines her breasts for masses, but does not do it regularly as she has never found any suspicious masses. Nutrition: Patient states she eats a predominantly traditional Mexican diet. She admits that she does not always eat the healthiest options. Exercise: The patient denies any regular exercise. Relevant Past Medical History General Health: The patient states that she felt in generally good health until this past Saturdays episode. Surgeries: Denies any previous surgeries. Blood Transfusions: Denies any blood transfusions Hospitalizations: Denies any hospitalizations except for the birth of her 6 children. Serious Accidents/Injuries/Fractures: Denies any. Major Illness: Denies any major illnesses Limitations of ADLs: Denies any limitations. Social History Home living conditions: Lives with one of her sons in a home. Occupation: Retired/unemployed former custodian. Currently babysits some of her grandchildren. Economic resources/concerns: Uninsured patient. Limited fixed income. Military record: None Religion: Catholic Patients Explanatory Model: Patient afraid she may have had a mild heart attack. Family History: Father had open heart surgery 7 years ago, history of hypertension and diabetes. Mother has history of hypertension and diabetes. One of her sons had a heart attack approximately one year ago in Afghanistan while deployed. Patient is unsure of her granparents history, but she states that all were deceased at relatively young ages, but unsure of exact ages. She has one daughter that had renal failure recently. One of her other daughters donated a kidney to the one with renal failure 2 months ago. Both have recovered from the surgeries well. Another daughter has hypothyroidism. ROS of Relevant Systems

General-Denies any changes in weight, energy level (except recent episode), appetite changes, trauma, injuries, or other constitutional changes. States that she has been having some difficulty falling asleep for past few months. Eyes-Denies visual changes, eye pain, headache, double vision or other visual changes. ENT-Denies any runny nose, nose bleeds, sinus pain, ear or hearing changes, or other ENT changes. Cardiovascular-Except for recent episode she denies chest pain, shortness of breath, exercise intolerance, orthopnea, palpitations, faintness, or loss of consciousness. Respiratory-Denies cough, sputum, wheezing or other respiratory changes. GI-Denies any abdominal pain, weight loss, indigestion, cramping, bloating, anorexia, nausea, vomiting, or constipation. She has had some difficulty with occasional diarrhea that she attributes to stress. Genitourinary-Denies any urinary problems. States that she is postmenopausal for about 112 years. Musculoskeletal-Denies any MSK issues such as pain, stiffness, or arthritic symptoms. Ingegumentary-Denies any skin changes. Neurological-Denies any changes in senses, seizures, fainting, headaches, balance, bowel/bladder control, weakness, speech function. Endocrine-Denies any endocrinologic changes. Hematology-Denies changes Psychiatric-denies depression, sleep changes, concentration issues, paranoia, anhedonia, mania, personality changes. She does state that she has been feeling some anxiety about her ex-husband. She has not had contact with her ex-husband for approximately 25 years. He was recently diagnosed with terminal lung cancer and her children have been taking care of getting him to appointments. She states that while she does not have any contact with him, she is disturbed by the effect his cancer is having on their children. She states that she is upset and feels that her ex-husband is taking advantage of the children since he has only had limited contact over the past 25 years until the time of his diagnosis. Objective Temp:98.7 oral, BP 160/84 repeated at 161/80, P 73 repeated 70, RR:18, Ht:59inches, Wt: 159lbs, BMI:32.0 Physical Exam Constitutional-Appears well nourished. Patient is well groomed and quietly sitting on the examination table. The patient does not appear to be in acute distress. She does seem somewhat anxious. Skin: Normal turgor without rashes or lesions.

HEENT-Conjuntiva non injected, EOM intact, PERRLA, TM grey with landmarks visible. Nasal passages patent with unremarkable membranes. Mouth has moist mucous membranes. Numerous dental fillings present. Lymph node-No lymphadenopathy. Thyroid-No thyromegaly. CV-RRR, S1S2. No abnormal sound present. Lungs-Unlabored breathing, symmetric expansion, clear breath sounds. Abdomen-Soft, non-tender, non-distended. Normal bowel sounds, no palpable masses. Neurologic-Cranial nerves intact. No weakness in upper or lower extremities. Diagnostic/lab data EKG done in clinic. No abnormalities noted on EKG, normal sinus rhythm. Blood sent: CBC, CMP, Lipid panel, A1C, TSH. Assessment Anxiety-Anxiety can cause dizziness, lightheadedness, palpitations (Dains, Baumann, & Schiebel, 2012).The patient admits that she has been having more stress than usual due to 2 of her daughters having surgery for the living related kidney transplant, her sons heart attack about a year ago, and the reemergence of her ex-husband with terminal lung cancer and her feeling that he is taking advantage of her kids. Angina-Anginal pain could be the cause of the patients symptoms based on the way the patient described the radiation of the pain down her left arm (Dains, Baumann, & Schiebel, 2012). It is not appropriate to rule this out without a further cardiac workup. The EKG done in the clinic shows a normal sinus rhythm and rate. Hypertension-The patients blood pressures indicate hypertension. GERD-Could cause chest pain symptoms and can cause shortness of breath (Dains, Baumann, & Schiebel, 2012). Ruled this out due to the patients lack of a history of reflux symptoms; however, if the cardiac workup is negative this diagnosis can be revisited. Plan Anxiety-Ativan 0.5 mg PRN Q 8 hours for anxiety. Discussed relaxation techniques with the patient and ways to decrease the stress that she perceives with her ex-husband and children.

Angina-Referral to local cardiologist to perform further cardiac workup including nuclear stress test. Called cardiologist to inform him of the patient and her self-pay status to try to get her worked in with a discounted price. Hypertension-Metoprolol Tartrate 50mg BID. This patients blood pressures are on the border between stage I and Stage II hypertension, so it could be argued that the patient should also have been started on a thiazide diuretic (Uphold & Graham, 2003). The decision to not start the diuretic at this time was made based on the paitents limited financial resources and the patients own admission that her diet contains a lot of sodium. Discussed need for a low sodium diet to help control her hypertension. The cardiologist she is being referred to has an extensive diet/exercise program that she can participate in at home without the extra costs of a gym or special foods. Metoprolol Tartarate was chosen over Metoprolol Succinate for this patient due to the availability of the Metoprolol Tartarate being available as a generic $4 prescription for this patient since she is currently uninsured. This is further discussed below. Followup This patient has not had a physical exam in many years, so we converted this episodic visit into a physical exam visit and were able to perform the labs and EKG required to thoroughly evaluate this patient. She will be returning to clinic in two weeks to follow up on her labs, to evaluate the effect of the metoprolol on her blood pressure, and to follow up on the recommendations of the cardiologist. The patient was advised of the importance to seek the care of the cardiologist as soon as possible to thoroughly evaluate her heart function. The cardiologist has agreed to see her early next week at a discounted price. The patient agrees that she needs the workup and states that she will make the appointment with cardiology. We explained to the patient the significance of the symptoms that she was having and urged her to seek emergency medical care in the event that she has another episode similar to the one she recently experienced. She stated understanding and agreed to call 911 or visit the ER if needed. Review of related article The article reviewed for this patient encounter is titled Health expenditure comparison of extended-release metoprolol succinate and immediate-release metoprolol tartarate. The article states that compliance with the medication regimen results in better hypertension outcomes for the patient. More importantly, it states that the complexity of hypertension medication regimens can lead to noncompliance. The article states that approximately 50% of the hypertensive population discontinues their antihypertensive medication within the first 6-12 months of initiation of therapy (Vaidya & Patel, 2012). Specifically, the article states that the number of patients on beta blockers and diuretics who abandon treatment is unusually high. The study found that the health outcomes from both the extended release and immediate release forms of metoprolol were similar. However, there was an increased cost for the extended release form over the cost of the immediate release form. In treating this patient, we could have given her the once daily extended release form of metoprolol in anticipation that the patient may remain compliant for a longer time period by only

having one pill to take daily. However, due to the patients financial limitations, the extended release metoprolol would have been more difficult for the patient to obtain making noncompliance more likely. The availability of a 30 day supply for $4 or a 90 day supply for $10 is more affordable for this patient as she specifically requested medications that could be had at the cheaper rate. While the treatment for this patient could have also included HCTZ, also available as a $4 or $10 generic, the addition of another pill could have complicated her treatment regimen possibly leading to treatment failure.

References Dains, J., Baumann, L., Scheibel, P. (2012). Advanced Health Assessment and Clinical Diagnosis in Primary Care, Fourth Edition. St. Louis: Elsevier. Uphold, C.R. & Graham, M.V. (2003). Clinical Guidelines in Family Practice. Gainesville, Fl: Barmarrae Books, Inc. Vaidya, V. & Patel, P. (2012). Health expenditure comparison of extended-release metoprolol succinate and immediate-release metoprolol tartarate. Clinicoeconomics and Outcomes Research, 2012(4), 49-56.