Identifying Data:

Full Name: E.H.

Address: Queens, NY

Age: 29

Date and Time: 6/1/2021 11:45 AM 

Location: StatCare Astoria

Religion: Unknown

Source of Information: Self

Source of Referral: Self

Reliability: Reliable patient 

Mode of Transport: Walked

Chief Complaint: intermittent palpitations x 1 month  

History of Present Illness: 

29 y/o F, with a PMHx of anxiety and hypothyroidism, who presents to urgent care complaining of intermittent palpitations for the last month. Patient states she feels the palpitations once a day and states it lasts approximately five minutes. She states she usually notices the palpitations when she is in a quiet environment. Patient does state she is on Citalopram for her anxiety and believes her anxiety is worse than usual. She denies fever, chills, weakness, weight loss, fatigue, insomnia, heat/cold intolerance, weakness, cough, shortness of breath, chest pain, diaphoresis, leg edema, back pain, abdominal pain, nausea, vomiting, diarrhea, dizziness, syncope or any other symptoms at this time. Patient reports her TSH was last checked seven months ago, and states it was within normal limits. She states she is compliant with her Levothyroxine and denies taking any other medications or supplements. She denies a family history of early cardiac death or arrhythmias. Patient states she smokes 1-1.5 packs of cigarettes a day.

Past Medical History: Hypothyroidism, Anxiety 

Past Surgical History: Denies 

Family History: Father – alive, HTN and HLD.    Mother – alive, thyroid disease 

Medications: Citalopram 10mg PO daily, Levothyroxine 25mcg PO daily 

Allergies: No known drug, food or seasonal allergies.  

Social history: Admits to smoking 1-1.5 packs per day and occasional alcohol use approximately three beers a week. Patient denies any illicit drug use. Patient works in a grocery store and lives with her mother and father. She reports second-hand smoke from her father as well. She denies regularly exercising. 

Review of Systems: 

General: Denies fever, chills, night sweats, fatigue, weakness, weight loss/gain or decreased appetite. 

Skin, hair, nails: Denies changes in texture, excessive dryness or sweating, discolorations, pruritis or changes in hair distribution.

Head: Denies headache, dizziness or head trauma. 

Eyes: Denies blurry vision, double vision or loss of vision. 

Ears: Denies hearing loss, discharge, tinnitus, ear pain. 

Nose/Sinuses: Denies nasal congestion, nasal discharge, sinus pressure/pain, or loss of smell.

Mouth/throat: Denies sore throat, bleeding gums, mouth ulcers. 

Neck: Denies localized swelling/lumps or stiffness/decreased range of motion.

Respiratory: Denies cough, shortness of breath, wheezing, sputum production. 

Cardiovascular: Admits to palpitations. Denies chest pain, leg edema, hypertension, syncope or known heart murmur. 

GI: Denies abdominal pain, nausea, vomiting, hematemesis, diarrhea or constipation. 

GU: Denies heavy vaginal bleeding, dysuria, hesitancy, flank pain, frequency, hematuria or urgency. 

MSK: Denies muscle or joint pain, redness or stiffness. 

Neuro: Denies weakness, dizziness, lightheadedness, headaches, sensory disturbances. 

Physical Exam: 

VS: T 98.2 F, BP 137/92, HR 111 bpm, RR 14, O2 sat 98%, Ht5’5”, Wt 170 lb, BMI 28.29 

Gen: Alert and oriented, in no acute distress. Well-nourished. Sitting comfortably in chair. Slightly anxious appearing. 

Skin: Warm and moist, no rash. No excessive dryness. 

Head: Normocephalic, atraumatic 

Eyes: PERRL. Sclera non-icteric. EOMI. 

Ears: Normal tympanic membranes

Throat: No erythema or exudates. Uvula midline. 

CV: Regular rate and rhythm. S1 and S2 with no murmurs. 

Resp: No respiratory distress. Clear to auscultation bilaterally. Non-labored breathing

Assessment: 

29 y/o F with PMHx of anxiety and hypothyroidism, who presents with intermittent palpitations, once a day, for one month. Vital signs were significant for tachycardia initially, but on physical exam the patient has a regular rate of 85 bpm and rhythm with no other findings. 

Differentials: hyperthyroid, anxiety, sinus arrhythmia, SVT, COVID-19 

Plan: 

• Order rapid COVID-19 antigen test – negative  
• Order CBC, CMP and Thyroid comprehensive with free T4
• EKG done in office showing normal sinus rhythm at 87 bpm. PR interval 174 msec, QT/QTc 342/389, QRS interval 102 msec, no ST elevations or depressions. 
• Discussed with the patient the negative COVID-19 test and normal EKG. 
• Discussed that the patient will receive a call from the Aftercare team when blood results return to develop a further plan as needed. 
• Discussed that the patient should go to the emergency department if she develops a prolonged fever not relieved by Tylenol, shortness of breath, difficulty breathing or chest pain. 
• Educated patient on ways to manage her anxiety and discussed smoking cessation. 
• Patient agreed with the plan and all questions were answered.