Kate Parker is a 64-year-old, Jamaican American female patient who comes to the clinic reporting “dizziness and near-fainting that has been happening off and on for the last 48 hours.

Kate Parker is a 64-year-old, Jamaican American female patient who comes to the clinic reporting “dizziness and near-fainting that has been happening off and on for the last 48 hours.” She reports a 10-year history of hypertension, which she describes as usually controlled. She considers herself as healthy, other than being recently ill with a bad case of influenza. Med list current (see below)—she took all medications as scheduled this morning.
She denies any pain, palpitations, angina, or signs of stroke (facial droop, arm weakness, or trouble with speech). Physical assessment reveals an irregular heart rate; weak peripheral pulses; cool, pale skin; and decreased capillary refill. The ECG shows atrial fibrillation. Ms. Parker reveals that she is in the United States illegally and is undocumented. The patient expresses concern about her status as you prepare her for treatment.
PMH
· Other active problems: hyperlipidemia and hypertension
· Medical, surgical, obstetric, hospitalizations: Appendectomy at age 20; no other hospitalizations or surgical procedures
Prescriptions and allergies
· Prescriptions (current)
o Nebivolol (Bystolic) 5 mg daily
o Lisinopril and hydrochlorothiazide 20/25 mg daily
o ASA 81 mg daily
o Atorvastatin (Lipitor) 40 mg daily
· Allergies: No known allergies to food or medicine
Preventive health
· Seen 6 months ago for a well-woman visit
o Pap smear and mammogram both normal
o Lipid profile:
§ Total cholesterol 220 mg/dL
§ HDL cholesterol 36 mg/dL
§ Triglycerides 152 mg/dL
§ LDL cholesterol 134 mg/dL
o Sees dentist yearly
o Last colonoscopy 5 years ago and within normal limits
· Immunizations
o Flu shot
o Pneumovax and Zostavax 6 months ago
o Last Tdap 2 years ago
FHx/SHx
· FHX (family history)
o Father died at age 78: stroke
o Mother died at age 85: heart disease
· SHS (social history)
o Occupation: cashier; emigrated from Jamaica; fluent in English
o Living situation: lives with husband of 30+ years in an apartment
o Alcohol use: 4 glasses of wine/week
o Tobacco use: none/never
o Illicit drugs: none/never
o Sexual history: monogamous
o Diet: high rice consumption; little red meat; lots of chicken, fish, beans for protein
o Exercise: walks 20 minutes three times a week
ROS (from patient interview)
· General/constitutional: Reports 6 hours of sleep normally at night; fatigued and weak
· Skin/breast: Normal
· HEENT and neck: Normal
· Cardiovascular: Felt dizzy on and off for the past 2 days; no chest pain
· Respiratory: Bad case of influenza 2 months ago; no recent cough, wheeze, or sputum production
· Abdomen/gastrointestinal: No history of peptic acid disease or gastroesophageal reflux. Last BM this morning (once daily is normal)
· Genitourinary: No use of estrogen; LMP at age 48
· Musculoskeletal: Normal
· Neurological: Intermittent dizziness and feeling near fainting over the last 2 days
· Allergic/immunologic: Normal
· Lymphatic/endocrine: No history of diabetes mellitus or thyroid disease
· Hematologic: No history of anemia
· Psychological: No history of anxiety, panic disorder, or depression
VS
· BP: 128/84
· HR:180
· RR: 30
· T: 99.1
· HT: 70’’
· WT: 197
· BMI: 28.27
Physical exam
· General: Appears in moderate distress
· Skin/breast: Cool, pale, no rash or lesions
· HEENT and neck: PERRLA. Thyroid WNL to palpation
· Cardiovascular: No jugular venous distension; point of maximal impulse (PMI) 5th intercostal space (ICS); tachycardic (180 bpm); irregular rhythm, no murmur; weak peripheral pulses; decreased capillary refill; no peripheral edema. EKG shows an absence of P waves, fibrillatory waves, irregular
· Respiratory: Breath sounds clear to auscultation and percussion; tachypneic
· Abdomen/gastrointestinal: Soft, nontender to palpation in all quadrants
· Genitourinary: Not examined
· Musculoskeletal: Normal, no edema
· Neurological: CN II – XII intact; DTRs +2; no facial droop, arm weakness, or tMusculoskeletal: Normal, no edema
· Neurological: CN II – XII intact; DTRs +2; no facial droop, arm weakness, or trouble with speech
· Psychological: Not examined
· Allergic/immunologic: NKDA, no food or seasonal allergies
· Lymphatic/endocrine: No lymphadenopathy
· Hematologic: Not examined

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