Identifying information: 32 years old, Caucasian female

Date: July 1, 2009

Source and Reliability: self, seems reliable

Chief Complaint: “severe chest pain for the past 48 hours”

History of Present Illness (HPI): Patient is a 32 year old Caucasian female complaining
of “intense, sharp chest pain for the past 48 hours.” She reports the pain being pleuritic
in nature. The patient states that a pain began suddenly when she woke up two days ago,
and since that time,” the pain has got more severe to the point that she can not handle this
any more”. She rates the pain a 9 out of 10, 1 being no pain, and 10 being intolerable
pain. Patient says that the pain is now “nonstop” and it is only slightly alleviated when
she sits up or leans forward, and getting much worse with a deep breath or lying down
position, and because of that she could not sleep for 2 days now. The patient states that
the pain is sharp, substernal, located “right in front of her anterior chest approximately
under the breastbone” and from there radiates to the upper abdominal area, left side of the
neck and shoulder. Patient mentioned that she has been experiencing severe fatigue,
chills, low grade fever, and mild shortness of breathe that started little after the onset of
the chest pain. Patient states that she just got over upper respiratory infection, which she
had for about one week prior to the onset of the chest pain. She has been taking 500 mg
of Tylenol extra straight every 4 hours for pain, without any relieve. Denies smoking or
using oral contraceptives. Patient denies any edema, phlebitis, hypertension, myocardial
infarctions, or exercise intolerance. She denies ever having an EKG or echocardiogram.
Denise any chest trauma, or radiation therapy. Denise taking procainamide, or
hydralazine medications. Patient denies any family history of related episodes. Reports
resent taking antibiotic Levaquin 500 mg QDx 5 days for upper respiratory infection,
which she “finished 2 weeks ago”. Denise any history of rheumatic fever, TB, mental or
hematological condition.

Patient states that she is in good health, denies history of any type of chest pain prior to
this episode. Reports occasional headaches and minor colds.

Past Medical History (PMH)

General state of health: Good

Past Illnesses : no history of hypertension, hart or lung disease, no history of rheumatic

or scarlet fever, croup, polio, chicken pox, pertussis, measles, diphtheria or mumps
Injuries: auto accident at age 21, no injuries or hospitalization.

Hospitalizations: see surgeries

Surgeries: appendectomy age 8, no complications, Hospital A, Doctor A

Allergies: not know allergies

Immunizations: tetanus – diphtheria boosters in childhood and then at age 11 (12/89).

Measles-mumps-rubella, polio, varicella, hepatitis B in childhood. Hepitits A series at
age 24 in 10/2003. Last tetanus shot 11/2004. Denies receiving Flu or Pneumonia
vaccine. Reports last PPD skin test 10/2008.

Substance Abuse: occasional smoking about 5 cigarettes a week for the past 11 -12
years. Reports social drinking, 2-3 glasses of white vine ones a month. Denies history of
any drug abuse.

Diet: mostly fish, chicken, vegetables. No change in appetite, eating pattern or weight.
Usual menu: breakfast – cottage cheese and cop of coffee with a low fat milk, lunch-
soup and sandwich, dinner – salad and peace of fish or chicken, snack – row vegetables.

Sleep patterns: normally sleep through the night, falls a sleep at 11 pm, awakens at 6 am

Current medications: Tylenol 500 mg 1 tab. PO PRN for occasional headaches

Multivitamins 1 tab. PO QD once a day

Alternative therapies: none

Health Maintenance: breast self exam monthly; last seen by GYN 11/08, no problem at
that time; Pap Smear and HPV test annually; has a protected sex; treadmill exercise 30
minutes every other day; see dentist on a regular basis, brushing/flossing teeth regularly;
never have an eye exam; wear UV sunglasses outside at all the time; uses sunscreen when
remember, washes hands.

Occupational and Environmental History: Work as a medical secretary in the primary

care physician office. Making appointments, doing failing, answering phone. She states
that she enjoys work. Never inhales any chemical or worked with asbestos.

Family History:
Paternal
Grandfather: 81 has CAD
Grandmother: 78 has HTN, DM
Father: 55, alive and well
Maternal
Grandfather had HTN, died age 80, of unknown cause
Grandmother: 75, has HTN, DM, CAD and arthritis
Mother: 53, has lupus

Brother: 24 alive and well

Husband: 33, alive and well
Children: no children

Not any known family history of mental diseases, TB, cancers, epilepsy, or hematological
disorders.

Psychosocial and Spiritual History: Patient was born in a big city. She is happily
married, has no children, but planning to have one in a few years, as soon as her husband
will finish his education. She works and going to school for her BS degree in Health
Administration. She is in a very close contact with her and her husband’s families; they
spend a lot of time together. She loves to spend time with them every other weekend.
Patient raised as an Catholic, but don’t really practice religion. Goes to church only if
“has some problem”, but feels guilty and would like to go more often.

Sexual, Reproductive, Obstetric and Gynecologic History: Patient is

Grav0/Para0/Ab0. Become sexually active at age 15, total numbers of sexual partners is
10, all men, and all before her marriage. In present time has “happy” relationship with
husband. Reports yeast infection 2-3 times a year over the past 2 years. Treated infection
herself with over-the-counter medications with good result. Denies any history of STI.
Denies any history of UTI. Reports occasional cold sores on her lip "from time to time",
but believes that it is related to “being out in the sun a lot”. Started menarche at age 12,
has a cycle every 28 days with duration 6-7 days. LMP 06/25/09. Denies dysmenorrhea,
abnormal bleeding, vaginal discharge, unusual odor, irritation. Reports little cramping 1
day before her period, reported flow as “average amount of dark red blood”. Do not use
any oral contraceptives, denies douching.

REVIEW OF SYSTEMS (ROS)

General: Describes general health status as good. Weight is stable for the past 10 years –
124 lbs, no recent changes. The patient denies any night sweats, or malaise.
Skin: No recent changes in skin texture, color, pigmentation. Reports small scars from
appendix removal in 1985. No dryness, rashes, purities, lesions, bumps or changes in hair
or nails.
Head: Occasional headaches, denies any trauma to the head. No dizziness, no vertigo
reported.
Eyes: Denies any changed/blurring vision, inflammation, pain, redness, swelling, itching,
photophobia, discharge, diplopia or scotomata.
Ears: Reports occasional ear infections as a child. At the present time denies any
earaches, infections, discharge, hearing loss, vertigo or tinnitus.
Nose: Occasional” runny nose”, usually subsides in 3-5 days. Denies trauma, obstruction,
allergy, sinus problems, and change of smell.
Mouth and Throat: Has occasional sore throats as a child. Denies dryness of
mouth/tongue, excessive salvations, dental problems, dysphalgia or hoarseness. No
postnasal drainage. No change of taste.
Neck: Denies pain, masses/lumps, swelling, tenderness or limitation of movement. .
Denies any enlargement, hardness, soreness, or masses of the lymph nodes.
Chest: Occasional URI, last chest X-ray 6/25/09 reported normal, no past history of
asthma, lung disease, or COPD. Denies any cough, wheezing, dysphagia, post nasal drip.
The patient denies any night sweats, or malaise.
Cardiac: see HPI
Vascular: no pain, swelling, numbness, discoloration, coldness, or varicose veins. No
history of TIA, CVA or claudication.
Breasts: Denies pain, discharge, lumps or tenderness. No history of breast disease or
surgery.
GI: No problem with appetite, food intolerance, flatulence, or dysphagia. No history of
nausea, vomiting, liver disease, jaundice, or colitis. Normal bowel movement, soft stool,
no diarrhea, constipation, no reported blood in the stool. Reports never having any
gastrointestinal work-up.
Urinary: reports no pain, hematuria, dysuria, oliguria, pyuria, frequency, urgency,
frequency, incontinence. No history of renal calculi.
Genitalia: no bumps, lesions, or rushes, lesions, or irritations
Musculoskeletal: No history of arthritis, joint pain, swelling, stiffness, deformities,
numbness, discoloration or coldness of extremities. No history of gout, muscle cramp or
pain. No history of back problems or deformity.
Neurologic: No history of fainting or blackouts, Denies loss of consciousness, seizures,
or syncope. No balance disturbance or memory disorders reported. Reports occasional
nervousness, or mood change in relationship with the weather; denies any history of
depression, hallucinations or mental health dysfunction.
Endocrine: no history of thyroid problem or diabetes, no increase urination, intolerance
to heat or cold, excessive sweating

PHYSICAL EXAM:

General Appearance: Well-groomed, pleasant woman who appears younger her age, in
severe distress
Vital Signs: Height: 5’ 5” Weight: 124 lbs B/P: 110/70 right arm lying, 110/70 right
arm sitting, 110/70 left arm lying, 110/70 left arm sitting. T: 38.3C Pulse: 102 Resp: 20
unlabored
Skin: Dry, intact, warm, turgor good. No rashes, lesions, swelling, petechiae, or
bruising. Nails beds pink, no clubbing. Hair has normal texture and disturbance.
Head: Normocephalic, no scaling, tenderness, lesions; symmetric and atraumatic
Eyes: PERRLA, EOMI. Acuity by Shellen chart OD 20/20 OS 20/20. No ptosis,
discharge, no strabismus. Conjunctivae and sclera has no lesions or redness. Vessels
present without crossing, no hemorrhage.
Ears: auricle symmetrical, canals nontender, canals clear and non-erythematous
bilaterally. Tympanic membrane intact and pearly gray. No mass, lesions, tenderness,
discharges. Rinne test: AC>BC, Weber – heard midline. Whispered words heard and
repeat clearly.

Nose: no deformities, mucosa pink, lo lesions, septum midline, clear discharge

Sinuses: no tenderness over maxillary or frontal sinuses
Pharynx: Mucous membranes moist. Lips without lesions, cyanosis. Uvula midline.
Tonsils grade 1+.
Neck: Supply, full range of motion. Denies pain or limitation of movement. Trachea
midline, thyroid not tender. No adenopathy. No jugular vein distention
Lungs: clear on auscultation and percussion
Heart: pericardiac friction rub, extra cardiac sound with both systolic and diastolic
components. Rapid heart rate, no pulsus paradoxus.
Breasts: even, no lesions, discharge. Consistency homogeneous, dense, no
lymphadenopathy, no masses, tenderness
Vascular: all peripheral pulses present bilaterally, 2+.
Abdomen: Abdomen symmetrical, soft, negative rebound, nontender. Normal bowel
sounds. Liver and spleen nontender, no masses.
Genitalia: no lesions or bumps external and internal, no discharge. Cervix pink,
nuliparous. No pain, tenderness or organomegaly.
Rectum: no hemorrhoids, lesions, masses or tenderness. Stool brown, soft, hematest is
negative.
Lymphatic: no swelling, tenderness, or masses
Musculoskeletal: normal range of motion, no deformities
Neurologic: patient is alert, oriented to place, person, and time, and current events. No
dysarthria, dysphonia, dysphasia, or aphasia. Patient has impaired judgment.
Demonstrated normal vocabulary, emotional responses calculated ability, objects
recognitions and memory.
Cranial nerves:
I Olfactory - intact
II Optic intact
III Oculomotor intact
IV Trochliar intact
V Trigeminal intact
VI Abducents intact
VII Facial intact
VIII Vestibulocochlear intact
IX Glossopharyngeal intact
X Vagus intact
XI Spinal accessory intact
XII Hypoglossal intact
Arm abduction Normal
Flexion and extension of the arm Normal
Forearm flexion Normal
Forearm extension Normal
Wrist extension Normal
Wrist flexion Normal
Finger adduction Normal
Finger abduction Normal
Thumb adduction Normal
Upper extremities tone Normal
Hip adduction Normal
Hip abduction Normal
Knee flexion Normal
Knee extension Normal
Ankle dorsiflexion Normal
Ankle plantar flexion Normal
Great toe dorsiflexion Normal
Great toe plantar flexion Normal
Lower extremity tone Normal
Reflexes
Stretch reflexes – 2+
Biceps tendon reflexes C5, 6 Normal
Brachioradialis C6 Normal
Triceps C7 Normal
Patellar L 2-4 Normal
Achilles S4 Normal
Superficial reflexes Normal
Babinsky reflex absent
Sensory function Normal
Cerebellar Function:
Finger-to-nose Normal
Heel-to-knee Normal
Papid alternating movement Normal
Romberg test Normal
Gait assessment Normal

ASSESSMENT:

1.The patient’s symptoms and physical findings suggest possible acute pericarditis. The
Center criteria for predicting pericarditis have been the most widely used and include:
a). Anterior, substernal, intense, sharp, pleuritic chest pain. b). Positional pain – relived
by leaning forward. c). Worse in inspiration d). Radiation to the left shoulder e). Fever
and chills. f). Irregular and rapid pulse. g ). Coarse pericardial friction rub, which is
louder with the patient sitting forward h ). Recent upper respiratory infection
2. constrictive heart disease
3. Pericardial cyst
4. Acute MI
5. Metastatic neoplasm
6. Renal failure
7. Connective tissue disease
8. Sarcoidosis,
9. Scleroderma
10. Aortic dissection
11. Pulmonary embolism
12. Esophageal rupture
13. Pneumothorax
14. Pancreatitis

PLAN:
Dx:

1. Electrocardiogram to r/o diffuse ST elevation, PR segment depression, T wave

inversion, PAC’s and atrial fibrillation. Differentiate from ECG of early
repolarization variant (ERV) by checking ST-T ratio.
2. CxR to r/o pericardial effusion
3. Echocardiogram to check for pericardial effusion and scarred or thickened
pericardium, to r/o cardiac tamponade and calculated left ventricular ejection
fraction
4. O2 saturation, JVP, pulsus paradoxus to r/o early tamponade
5. CBC with the Sed Rate to r/o infection
6. ANA to r/o lupus and other collagen-vascular disease
7. Thyroid function test to r/o myxedema
8. Serum albumin and urine protein to r/o nephritic syndrome
9. Serum creatinine and BUN to r/o ranal failure
10. Criatine kinase, which should be normal with pericarditis
11. HIV
12. Chest/abdominal/pelvic cat scan if needed to better assess thickening of
pericardium and pericardial effusion and r/o possible primary tumor (attention to
lung and breast)
13. TB skin test to r/o bacterial infection
14. Cardiac catherization if needed to confirm diagnosis, to show equalization of
diastolic pressure in all four chambers.

Tx:
1. Codeine 30 mg Q4-6 PRN pain
2. Aspirin 650 mg QID for 2 weeks
3. Prednisone 60 mg/d initially, tapered over 7 days
4. Possible diuretic Lasix 20 mg QD for 7 days if pericardial effusion present

Pt. Ed/Referral/Follow-up:
1. Close monitoring for any increased in intensity chest pain, if there any change of
condition considering admitting to the hospital.
2 Acute pericarditis is a self limited syndrome in most cases, which is very low
probability of permanent adverse effects. There is a small possibility to progress
to chronic constrictive pericarditis. In some cases it could be relapsing or
recurrent acute pericarditis over month or years. The recurrent episodes are
usually benign, and less severe. To avoid relapse give the patient corticosteroid
medication, which she will take together with Aspirin and Codeine. Aspirin is
 Platelets inhibitor and will decrease patient’s risk for the MI. If patient will not
get any release from the Codeine, she may need Morphine, if lab test would
confirm diagnosis of pericardial effusion she may need a diuretic medications.
3 See cardiologist for the further evaluation of the chest pain ASAP
4 Call the office right away if symptoms would get worse
5 Pericarditis cannot be prevented, but a healthy lifestyle, exercise and proper diet,
will help keep the body's immune system strong and ready to fight off dangerous
microorganisms.
6 Take prednisone with food or milk, do not stop abruptly, watch for fatique,
muscle weakness, joint pain, anorexia, nausea, fainting, sadden weight gain or
swelling
7 Take codeine 1 tab every 4-6 hours as needed for pain.
8 Take aspirin 650 mg 1 tab once a day with food, for 2 weeks, watch for the
evidence of hemorrhage, such as petechiae, bruising, coffee ground vomiting, and
black tarry stools.
9 Patient showed complete understanding of education
10 Return for a follow-up visit in 7 days

Identifying information: 25 days old, Caucasian female

Date: July 1, 2009

Source and Reliability: mother, seems reliable

Chief Complaint: “fever for the past 24 hours”

History of Present Illness (HPI): history is given by newborn’s mother, who is not very
good historian. Patient is a 25 days old Caucasian female brought to the clinic by her
mother, who is complaining that her 25 days old newborn baby was doing good until
approximately 24 hours ago, when she developed fussiness, irritability, “start crying and
refused to eat”, approximately 6 hours ago baby had some vomiting, and then developed
fever up to 38.8C.
Mother states that baby was in a good health, till now, this is her first” health issue” since
she was born. Mother denies history of any previous health problem.

Past Medical History (PMH)

General state of health: Good

Past Illnesses : no history of hart or lung disease, no history of any fever, croup, polio,
chicken pox, pertussis, measles, diphteria or mumps
Injuries: none
Hospitalizations: none
Surgeries: none
Allergies: not know allergies
Immunizations: hepatitis B at birth

Prenatal status: Mother was seen Doctor B for her prenatal care on a regular bases. Her
first visit to the clinic was at 6 weeks of pregnancy. Mother described pregnancy as “easy
and fun”. No high blood pressure, nausea or vomiting. Denies smoking, alcohol,
prescription or illegal drug use during pregnancy, no x-ray studies was taken during
pregnancy.

Labor and Delivery: Mother is 30 y.o. Gravida 0, Para 0 who delivered on June 5, 2009.
Reports 8 hours of labor. Normal vaginal delivery at 39 weeks gestation at Hospital A by
doctor D. Baby presentation was vertex, no anesthesia

Postnatal status: Weight at birth 8 lbs, 05 ozs. Length 23 inches. Apgar sore 9. Mother
reports infant to be healthy at birth with “normal head and chest measurements” .Baby
was breast fed. Mother reports no feeding problems, baby gain weight normal.

Substance Abuse: Mother denies any smoking, alcohol or drug abuse at present time as
well

Diet: Breast milk, every 3-4 hours, appetite is good. Regular stool up to 5 times a day,
no constipation or diarrhea

Sleep patterns: sleeps well, wakes up every 3-4 hours around time for breastfeeding

Current medications: none

Alternative therapies: none

Health Maintenance: breast feeding, no sun exposure, follow by regular pediatrician,

has a health insurance

Occupational and Environmental History: mother was always housewife, now she
spends all her time with infant; father is an engineer, very supportive.

Developmental History: Demonstrates development/behavioral milestones. Weight: 10

lbs; Height: 27 inches. Infant is exploring extremities, holding his head up, track objects
with both eyes.

Family History:

Paternal
Grandfather: 57, alive and healthy
Grandmother: 55, alive and healthy
Father: 35, alive and well

Maternal
Grandfather 55, has HTN
Grandmother: 54, alive and healthy
Mother: 30, alive and healthy

The baby is only child

Not any known family history of mental or other chronic diseases, no family history of
TB or cancers.

REVIEW OF SYSTEMS (ROS)

General: mother describes baby’s general health status as good.

Skin: denies any body odor, rashes under diaper area, lesions, swelling, bruising, or birth
mark.
Head: denies any anterior fontanelle bulging, drooling, face asymmetry or swelling
Eyes: denies any redness, swelling, or discharge.
Ears: denies any pain, discharge
Nose: Denies any running nose, trauma, obstruction, allergy, or sinus problems
Mouth and Throat: denies cyanosis, lesions, swelling
Neck: Denies pain, masses/lumps, swelling, tenderness or limitation of movement.
Chest: denies any asymmetry, trauma, wheezing, congestions.
Cardiac: denies any heart problem
Vascular: denies any problem
Breasts: Denies pain, discharge, lumps or tenderness.
GI: See HPI
Urinary: report no crying with urination, normal color of the urine
Genitalia: denies bumps, lesions, or rushes, lesions, irritations, or discharge
Musculoskeletal: denies pain, deformity, reports equal movement of both hands and
legs.
Endocrine: not known diabetes, thyroid problem, tremor, or excessive sweating. Baby
does not taste salty.

Neurologic: no history of seizur

PHYSICAL EXAM:

General Appearance: Well-groomed, well developed newborn girl

Vital Signs: Height: 60 cm Weight: 9 lbs T: 38.8C Pulse: 130 Resp: 30 unlabored
Skin: no body odor, no rashes under diaper area, lesions, swelling, bruising, or birth
mark. Nails beds pink, no cyanosis or clubbing . No visible hair
Head: The anterior fontanelle is not bulging, no drooling, face is symmetrical
Occipitofrontal head circumference is normal
Eyes: no crossed eyes, no tearing, no optokinetic nystagmus
Ears: symmetrical, no pain, discharge
Nose: no nasal discharge, symmetrical septum, no masses or foreign body
Sinuses: no tenderness over maxillary or frontal sinuses
Pharynx: Mucous membranes moist. Lips without lesions, cyanosis. Uvula midline.
Tonsils grade 1+.
Neck: no stiffness, tenderness, lumps, lymphodenopathy
Lungs: clear on auscultation and percussion, no cough, hoarseness, no respiratory
distress, no tachypnia, no stridor
Heart: The heart rate is normal for the baby’s age, no murmur, no cyanosis, no sign of
tachycardia,
Breasts: even, no lesions, discharge. Consistency homogeneous, dense, no
lymphadenopathy, no masses, tenderness
Extremities: The extremities are normal. No Kernig's or Brudzinski sign, pulses are
present
Abdomen: Abdomen symmetrical, soft. Normal bowel sounds. Eats breast milk only, no
diarrhea, jaundice, crying and drawing legs up, no liver enlargement. Umbilical cord
stump still present, looks dry
Genitourinaty: no lesions or bumps external and internal, no discharge. Has about 7-8
wet diapers a day, urinary stream is normal, no crying with urination.
Rectum: no hemorroids, lesions, or visible masses
Lymphatic: no swelling, tenderness, or masses
Musculoskeletal: no pain, deformity, moves hands and legs equal, no callus formation in
the clavicle. Hips are not dislocated.
Neurologic: No tremors or seizures
Reflexes
Stretch reflexes – 2+
Biceps tendon reflexes C5, 6 Normal
Brachioradialis C6 Normal
Triceps C7 Normal
Patellar L 2-4 Normal
Achilles S4 Normal
Superficial reflexes Normal
Moro Normal
Planter grasp Normal
Palmar grasp Normal
Sucking Normal
Rooting Normal
Stepping Normal
Swimming Normal
Tonic neck Normal
Babinski Normal
Blinking Normal
Cranial Nerve Exam
1. Pupil reflex - Cranial Nerve II - Normal
2. Doll's Eyes - Cranial Nerve III, Cranial Nerve IV, Cranial Nerve VI - Normal
3. Corneal, sucking, and rooting reflexes - Cranial Nerve V,Cranial Nerve VII - Normal
4. Response to noise - Cranial Nerve VII - Normal
5. Gag Reflex - Cranial Nerve IX, Cranial Nerve X - Normal

ASSESSMENT:

The patient’s symptoms and physical findings suggest possible:

 1. Flu
1. Viral infection
2. Urinary tract infection
3. Viral meningitis
4. Poor nutrition

PLAN:
Dx:
1. CBC
2. Electrolytes
3. Urinalysis
4. Urine C&S
5. Possible Lumbar puncture to obtain CSF
Tx:
1. Pedialyte as directed
2. Tylenol infant drops 0.5 ml Q6 hours for the fever more than 102F
3. Home remedies

Pt. Ed/Referral/Follow-up:
1. Carefully monitor patient for a possible meningitis, look for irritability or
lethargy; skin rash, such as vesicular, macular, petechial; tachypnea or apnea;
bulging fontanelle; vomiting, diarrhea, jaundice; altered sleep pattern.

2. Keep a daily temperature chart

3. Give a baby Pedialyte
4. Give Tylenol infant drops if needed
5. Look for the other signs and symptoms, such as EENT.
6. Teach parents to call right away if symptoms will get worse
7. Return in 3 days