A 64-year-old woman presents to you complaining of chest palpitations-Review of Systems

A 64-year-old woman presents to you complaining of chest palpitations. She states that she was watching TV and suddenly her heart started racing and pounding. She became light-headed and felt a bit better after a while. She reports she hears her heart beating when lying down. She is concerned and now presents for evaluation. She reports having mild palpitations in the past but nothing like this. She has a history of irregular heart beats years ago, but has not taken any aspirin for nearly a year. She said her surgeon told her it could be problematic before he took her kidney out. She was diagnosed with renal cell cancer 9 months ago and is now 6 months post right nephrectomy. She denies any chest pain or syncope. This visit is the first once since her nephrectomy.

Review of Systems

Positive for chest palpitations, generalized weakness, and SOB.

Her ROS is negative for weight loss or gain, fever, chills, vomiting, diarrhea, constipation, and chest pain.

Pat Medical History:

HTN, Renal Cell Cancer, CAD, GERD and a “Heart Murmur”

She states that she is being watched closely to make sure she does not show up with kidney cancer somewhere else. Surgical history is positive for a nephrectomy 4 months ago. The patient is a widow and lives with her only child, an unmarried son. She denies tobacco use, alcohol use, or any illicit drug use.

Her family history is positive for CAD, HTN and Type II DM, but negative for cancer.

Allergies—no known food or drug allergies.

Medications—Lisinopril 20 mg PO QD; Metoprolol succinate extended release 50 mg PO QHS; Multivitamin 1 PO QD

 

Physical Examination

Vitals: T 98.3°F, P 130, R 18, BP 130/74, WT178 lbs., HT 63 in., BMI 31.5.

General: 64 year old female, well groomed; appears her stated age; in no acute distress.

Psychiatric: Smiles; is cooperative and answers all questions appropriately though slightly slow to respond but states this is her baseline after the nephrectomy and her surgeon said it is to be expected.

Chest/Neck: no carotid bruits, no obvious JVD, but there is scant pretibial edema

Lungs: Nonlabored, chest rise symmetrical, lungs clear upon auscultation—but there are late inspiratory crackles in both bases posteriorly; pulse oximeter reading on room air is 97%.

Heart: Irregular rhythm and rapid heart rate, systolic murmur right sternal border grade 3/6.

Neurologic: Alert awake and oriented to person place and time; her affect is flat; motor and sensory is intact; deep tendon reflex 2+ bilaterally; Romberg is negative

POC Labs: CBC reveals normal platelets, Hemoglobin of 11 grams and a Hematocrit of 33%; Basic metabolic panel reveals normal values with a creatinine of 0.9 mg

1. List 5 differential diagnosis
2. List initial treatment plan and testing
3. What Rx’s are appropriate
4. List nursing interventions and education