HPI (History of Present Illness): Mrs

HPI (History of Present Illness): Mrs. Beverly Hansen is a 78 year-old female who presents to Valley Regional Medical Center’s Emergency Department, where you work as a nurse. Mrs. Hansen has experienced a fainting episode. She tells you “I was out walking this morning when I started to feel lightheaded and sweaty, and then I felt weak and nauseated. Next thing I knew, my neighbor was calling to me. I was lying on the ground. My head and hip really hurt. I guess I bruised them pretty badly.” Mrs. Hansen complains of muscle aches all over her body. The ED doctor on call at Valley Regional Medical Center is Dr. Frank Bennett. Mrs. Hansen’s primary care doctor is Dr. Maggie Carter. Past Medical History: MI (three years ago), she has a stent in her right coronary artery Stable Angina Atrial fibrillation Hypertension Type 2 Diabetes Mellitus (x20 years) Diabetic Neuropathy Obesity Anxiety Insomnia Irritable Bowel Disorder Medications (she insists that she takes all daily as prescribed, using a pill box to help her remember, and injecting her insulin glargine after drawing it up into her syringe carefully): aspirin, 81 mg, PO, daily apixaban (Eliquis), 5 mg, PO, 2 times per day atenolol (Tenormin), 50 mg, PO, daily lisinopril, 30 mg, PO, daily hydrochlorothiazide, 25 mg, PO, daily lovastatin, 40 mg, PO, bid nitroglycerin, 0.4 mg, sublingually, prn insulin glargine (Lantus), 10 units, SubQ, each morning *Look under Insulins, long- acting, in Davis’s Drug Guide to find this medicine metformin, 500 mg, PO, three times a day gabapentin, 300mg, PO, bid tramadol, 50 mg, PO, every 6 hours, prn valerian root, 1 tablet, every evening at bedtime, (unsure of dose) Allergies: none Surgeries: s/p angioplasty with stent placement s/p open appendectomy (“in my teens”) s/p hysterectomy for benign indications (30 years ago) Social History/Lifestyle: Habits: Cigarettes: 20 pack-year history, quit 3 years ago Alcohol: occasional cocktails on the weekends with her “girlfriends,” usually no more than 3 Exercise: walks daily for 30 minutes, “on my doctor’s orders” Diet: 3 small meals/day which are “healthy” Breakfast: toast, cereal with skim milk, fruit, grapefruit juice, Lunch: half sandwich (tuna, chicken or egg salad), soup, coffee or tea Dinner: whole grain pasta, vegetables Physical Examination: BP: 148/92, P: 84, RR: 22, T: 37.3 Obese, anxious female in supine position Head: large ecchymosis over left brow, edema and tenderness over left side of skull Neuro: no focal neurologic symptoms, patient is alert and oriented to name, day of week and time of day, place and situation Lungs: bilateral fine crackles over lower posterior fields Heart: regular rate, rhythm, no murmurs or additional sounds Abdomen: o