Clinical Dates: 03/10/2020
Patient Initial: BB, 80 years old, African American Female
1. 80 years old African American female present to the clinic for her Annual visit with her grandson. The patient complains of shortness of breath, dizziness and palpitation when she lay down, turns to her side, or bent down. The patient states, " I was sick last year around April, I think. She also mentions that she was admitted at Dekalb Medical Center for the same reason". Per patient her Atenolol was decreased because of that. Per her son Steven Albert McPhersons who spoke to us over the phone, the dizziness, palpitation, and SOB are not new; it is ongoing. He also mentions he took his mother to the cardiologist but couldn't remember if he took her to Neurologist or did an MRI. He also says some of her issues are because of her hearing loss in the left ear. Per patient, she had an MRI done, and the doctor said she had a stroke, but she couldn't remember when and where the MRI was done or the doctor's name that told her. The patient wants all her medications to be refilled.
Patient History of: Hypertension, Heart Murmur, Hyperlipidemia and Diabetes
Allergy: NKDA
Medication:
Aspirin 81 mg daily
Metformin 500mg 1 tablet po twice a day with meal
Amlodipine 10mg 1 tablet po daily
Atenolol 50mg 1 tablet po daily
Meclizine HCL 25 mg 1 tablet chewable as needed twice a day
Niacin 500mg 1 tab three times daily
Enalapril Maleate 10mg 1 tab daily
Atorvastatin calcium 40mg 1-tab po at bedtime
Family history
Father deceased- history of hypertension
Mother deceased -Malignant Neoplasm of unspecify site
6 sons- Alive and healthy
2 daughters – alive and healthy
Surgical History:
Denies any surgery
Social History”
Denies smoking, drinking or drugs
Walks three times a week
Retired and a Widow
Vital Signs
Temp:98.2, Heart rate: 62, Respiratory:18, BP: 149/74, 02SAT: 98%
HT-CM 163.83cm, Wt.-kg 72.67