CARDIAC ASSESSMENT
HEART & PERIPHERAL VESSELS
Pt. Initials: M.D.
Gender: F
Age: 43
Allergies: Augmentin – hives/rash
S:
CC: “My feet and legs are swelling”
HPI:
43 y/o F with CC of “My feet and legs are swelling.” Pt states it began a week ago and
remains constant. Standing and walking around makes it worse, but nothing really makes
it better. No pain associated, but skin feels tight and looks shiny. It also feels tight when
putting on shoes.
PMH:
Hypothyroidism dx in 2011, chronic HTN diagnosed in 2001, Bipolar disorder diagnosed
in 2013. Medications include Synthroid 50mcg daily, Wellbutrin 150mg slow release
BID, Effexor 75mg daily, Lamictal 100mg BID, Trazadone 50mg PRN for insomnia.
Surgical hx includes jaw surgery in 1992 for overbite correction, tonsillectomy in 1996,
and breast reduction in 2006, partial thyroidectomy in 2011, and a D&E in 2019 after
missed abortion at 12 weeks gestation.
FH:
Pt states parents and brother have chronic HTN.
SH:
Pt states walking and jogging 3-4 times a week. Occasional weights and daily ab
workouts. Has been exercising this way for about 5 months, with brief suspension due to
miscarriage and D&E. Alcohol intake about once a week, but does not binge. Denies
tobacco use and illicit substance use. Pt states an overall healthy diet, with occasional
“cheat days,” and adequate water intake. Pt would like to lost about 10 more lbs, but is
generally okay with weight.
ROS:
General: Denies significant weight changes, weakness, fatigue, fever.
HEART & PERIPHERAL VESSELS
Pt. Initials: M.D.
Gender: F
Age: 43
Allergies: Augmentin – hives/rash
S:
CC: “My feet and legs are swelling”
HPI:
43 y/o F with CC of “My feet and legs are swelling.” Pt states it began a week ago and
remains constant. Standing and walking around makes it worse, but nothing really makes
it better. No pain associated, but skin feels tight and looks shiny. It also feels tight when
putting on shoes.
PMH:
Hypothyroidism dx in 2011, chronic HTN diagnosed in 2001, Bipolar disorder diagnosed
in 2013. Medications include Synthroid 50mcg daily, Wellbutrin 150mg slow release
BID, Effexor 75mg daily, Lamictal 100mg BID, Trazadone 50mg PRN for insomnia.
Surgical hx includes jaw surgery in 1992 for overbite correction, tonsillectomy in 1996,
and breast reduction in 2006, partial thyroidectomy in 2011, and a D&E in 2019 after
missed abortion at 12 weeks gestation.
FH:
Pt states parents and brother have chronic HTN.
SH:
Pt states walking and jogging 3-4 times a week. Occasional weights and daily ab
workouts. Has been exercising this way for about 5 months, with brief suspension due to
miscarriage and D&E. Alcohol intake about once a week, but does not binge. Denies
tobacco use and illicit substance use. Pt states an overall healthy diet, with occasional
“cheat days,” and adequate water intake. Pt would like to lost about 10 more lbs, but is
generally okay with weight.
ROS:
General: Denies significant weight changes, weakness, fatigue, fever.
