CC: Lightheadedness, palpitations and presyncope. HPI: The patient is an xx-year-old male presenting to today with complaints of lightheadedness, palpitations, and presyncope. He noted lightheadedness 3 hours ago with palpitations and syncope. He drank a 5-hour Energy drink this morning which could have precipitated his symptoms. He has a similar episode previously where he had palpitations. He decided to get himself evaluated and was on his way to the ER, but his palpitations resolved, and he returned home. He was walking up the stairs when he felt lightheaded which is worsened with exertion. He denies any shortness of breath or nausea. He denies chest pain, but admits to chest discomfort with heart racing. He denies any abdominal pain, diarrhea, black tarry stools, or blood in the stools. He denies any fever, runny nose, cough, sore throat, congestion, vision changes, or one-sided lower extremity weakness, or feeling of weakness allover. He feels tired. He denies any leg pain or swelling. No recent travel or recent surgery. No DVT or PE. He had mild sweating. He saw Dr. ____ 3 years ago for lightheadedness. At that time, he had a stress test which was normal. He has done well since then until the episode of lightheadedness this morning. He has diabetes and had rheumatic fever when he was a child. He usually does not take his diabetes medications regularly. He has high blood pressure but does not take medications prescribed to him. REVIEW OF SYSTEMS: Positive fatigue. Positive mild sweating. Positive lightheadedness, palpitations and presyncope. Negative fever, runny nose, cough, sore throat, congestion, vision changes, or one-sided lower extremity weakness, or feeling of weakness allover. Negative leg pain or swelling. PHYSICAL EXAMINATION: HEENT: Posterior oropharynx is clear. Unable to visualize his optic fundus. Lymphatics: I do not feel any lymph node swelling. Neck: No carotid bruit. Neck is supple. Heart: He is tachycardic, about 150 on the monitor. He is irregularly irregular. Lungs: Mildly diminished at the bases, but otherwise clear. Abdomen: No abdominal bruit. No abdominal tenderness. Extremities: Equal radial pulses bilaterally. Negative Homan sign. Trace edema bilateral lower extremities. Assessment/Plan: Ordered stool guaiac, thyroid function tests TSH with reflex T4, troponin, CBC, BMP, magnesium and phosphorus level. Ordered EKG and chest x-ray. He was given aspirin. EKG FINDINGS: EKG was performed at 12:21 and read at 12:23. It shows sinus tachycardia with a rate of 115, normal P-waves, left ventricular hypertrophy, left axis deviation. He does have some ectopy including a PVC. There are no ST-T wave changes other than nonspecific due to the left ventricular hypertrophy. They do have poor R-wave progression, however, these changes are similar to previous other than rate and the PVC. The prior EKG was performed on 12/23/2015.
HISTORY OF PRESENT ILLNESS: The patient had become lightheaded about three hours before and felt as if his heart was racing; he thought he had passed out. He had a previous episode of his heart racing, so he went to the emergency room, where his symptoms subsided and he drove home. He had five hours of energy this morning. He did see Dr. Whiskey for lightheadedness about three years ago. They did a stress test at the time, and he never saw him again. The symptoms began when he was walking up the stairs, and he feels a little tired. He mentioned that he had a history of diabetes. He did not check his sugar level on a regular basis; instead, he checks it frequently. He is perspiring a little. As a child, he had rheumatic fever. I mentioned that rheumatoid fever can cause heart problems. He has a history of hypertension and is taking medication to treat that. PHYSICAL EXAMINATION HEEHT: The posterior oropharynx is clear and the optic fundus cannot be seen. Neck: There is no swelling of the lymph nodes in the neck. There are no carotid bruits. HEART: He has tachycardia. His heart rate is approximately 150 beats per minute and is irregularly irregular. He is diminished at the bases, but otherwise clear. ABDOMEN: There are no abdominal bruits. There is no tenderness in the abdomen. EXTREMITIES: He has equal radial pulses on both sides of his body. Homan's is negative. He had trace edema in both lower extremities. REVIEW OF SYSTEMS: Negative: Shortness of breath, chest pain, pain in heart, abdominal pain, diarrhea, black tarry stools, blood in the stool, fever runny nose, cough, sore throat, congestion, vision changes, weakness in one arm, leg, leg pain, leg swelling, travel or surgery, pulmonary embolism or deep vein thrombosis. Positive: His chest feels uncomfortable and feels his heart rising. heart. He is exhausted. IMAGING STUDIES: An EKG was performed, which revealed sinus tachycardia at 115 beats per minute, normal P-waves, left ventricular hypertrophy, left axis deviation, ectopy, and PVC. Other than the rate and the PVC, there are no ST-T wave changes other than nonspecific due to left ventricular hypertrophy and poor R-wave progression. The previous EKG was done on 12/23/2015. ASSESSMENT AND PLAN 1. Heart rising: To determine the cause of his heart rising if he has bowel movements, we will need to check his stool for blood. I have ordered a stool guaiac, thyroid function test, TSH with reflex T4, troponin, CBC, BMP, magnesium, and phosphorus level. I prescribed aspirin. 2. Cardiac: I requested an EKG and a chest x-ray.
