HPI: 55-year-old female presents today with complaints of palpitations that have been ongoing for the last month. Patient states the palpitations come and go through out the day and that she has been under a lot of stress lately. The palpitations do not have a pattern and they come throughout the day in no particular order. She denies chest pain, shortness of breath. She is well hydrated and has been eating normal.
Medications: HCTZ 12.5mg Qd
Lisinopril 5mg Qd
Atorvastatin 40mg Qd
Allergies : NKDA
No alcohol uses
Denied: History of Alcohol Use (History)
Denied: History of Drug Use
General: no fever, no chills, not feeling poorly, not feeling tired, no recent weight gain and no recent weight loss
Respiratory: no shortness of breath, no cough, no orthopnea, no wheezing, no shortness of breath during exertion and no PND.
Cardiovascular: Denies chest pain, denies palpitations, denies swelling to B/L lower extremities
Vital Signs: BP 124/68 HR 77 RR 18 Temp 98.6 Pox 98% RA
Constitutional: Patient is well appearing, Alert and Oriented x3 answers questions appropriately. Skin is warm and dry.
Cardiovascular: regular rate and rhythm, S1 and S2 identified with no rubs, murmurs, or gallops. No S3 or S4 noted. No clubbing or cyanosis noted to extremities. Bilateral lower extremities without edema. Pedal pulses strong and equal bilaterally.
Respiratory: Lungs clear to auscultation bilaterally no wheezing, Rhonchi, crackles, or rales noted
Assessment/Plan: After assessing the patient and performing an EKG a diagnosis of anxiety was made. Patient was told to follow up with her cardiologist and was given a referral to see a psychiatrist.
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