Daniel DeMarco                        H&P #1                                    Internal Medicine

Chief Complaint: Shortness of Breath since last night

History of Present Illness:

PR is a 75yo female former 40 pack-year smoker with PMH significant for CAD, Paroxysmal Atrial Fibrillation, HTN, HLD, chronic combined systolic and diastolic heart failure, s/p CABG with Bioprosthetic Mitral Valve Replacement, s/p Right-sided Pacemaker, s/p stent to mid RCA, s/p left sided carotid endarterectomy, Anemia of Chronic Disease, Type II Diabetes Mellitus, CKD Stage IV, Hypothyroidism, Chronic Vertigo, Anxiety, and Cervical and Lumbar Spinal Stenosis. Patient states she started experiencing shortness of breath last night that woke her from sleep. It has been constant since last night. Lying flat worsens the shortness of breath. Sitting up helps. Additionally complains of non-radiating chest pressure. She has experienced this in the past. Admits paroxysmal nocturnal dyspnea, two-pillow orthopnea, chronic non-productive cough, weakness. Denies weight gain, fever, chills, nausea, vomiting, palpitations, wheezing, hemoptysis.

Patient with recent hospitalization at Winthrop Hospital for CHF exacerbation (03/03/2019-03/08/2019). She was discharged on Torsemide 80mg bid. Dr. Manino decreased dose to 40mg bid during follow up appointment last week. Patient states she was adherent to medication, diet, and strictly monitored weights. Patient did not weigh herself this AM.

Patient received Furosemide 40mg IV in ED.

Past Medical History: CAD, Paroxysmal Atrial Fibrillation, HTN, HLD, chronic systolic and diastolic heart failure, s/p CABG with Bioprosthetic Mitral Valve Replacement, s/p Right-sided Pacemaker, s/p stent, s/p left sided carotid endarterectomy, Type II Diabetes Mellitus, CKD Stage IV, Hypothyroidism, Chronic Vertigo, Anxiety, Cervical and Lumbar Spinal Stenosis

Past Surgical History: Tonsillectomy (Child, Unknown Year), CABG LIMA to LAD with Bioprosthetic Mitral Valve Replacement (2017), Left Carotid Endarterectomy (2005), Right-sided Pacemaker (2011), Stent to Mid RCA (2012), B/L Knee Replacement (Left 2013, Right 2017)

Allergies: No known medical allergies, environmental, or food allergies

Medications: Aspirin 81mg PO qd, Carvedilol 12.5mg PO bid, Clonazepam 0.5mg PO bid, Hydralazine 50mg PO tid, Insulin Glargine 18u qhs, Insulin Lispro 6u ac, Levothyroxine 125mcg PO qd, Rosuvastatin 40mg PO qd, Sertraline 100mg PO qd, Warfarin 4mg PO one time Sat Sun Tues Thurs, Warfarin 6mg PO one time Mon Wed Fri, Amlodipine 10mg PO qd, Torsemide 40mg bid, Potassium 20mEq PO qd

Social History: Lives with husband. Former smoker, 40y, 1 pack per day, 40 pack-years. No EtOH use. No illicit drug use.

Family History: Father, Deceased, 44yo, CAD, MI; Mother, Deceased, ?yo, Lung Cancer; Brother, Deceased, 21yo, Accident

Review of Systems :

General : Admits weakness. Denies fever, chills, night sweats, fatigue, loss of appetite, weight loss

Skin, Hair, Nails : Denies change in texture, excessive dryness or sweating, discolorations, pigmentations, moles, rashes, pruritus, change in hair distribution

Head : Admits vertigo. Denies headache, trauma, unconsciousness, coma, fracture

Eyes : Denies corrective lenses, visual disturbances, fatigue, photophobia, pruritus, lacrimation, Last Eye Exam: 10/2018, Dr. Graham

Ears : Denies deafness, pain, discharge, tinnitus, hearing aids

Nose/Sinuses : Admits rhinorrhea. Denies discharge, epistaxis, obstruction

Mouth/Throat : Denies bleeding gums, sore tongue, sore throat, mouth ulcers, voice changes, dentures, Last Dental Exam: 04/2018, Dr. Umagi

Neck : Denies lumps, swelling, stiffness, decreased range of motion

Breast : Denies lumps, nipple discharge, pain

Respiratory : Admits dyspnea, shortness of breath, nonproductive cough, two-pillow orthopnea, paroxysmal nocturnal dyspnea. Denies wheezing, hemoptysis, cyanosis

Cardiovascular : Admits chest pressure. Denies palpitations, irregular heartbeat, edema, syncope, known heart murmur

Gastrointestinal : Denies change in appetite, abdominal pain, intolerance to specific foods, nausea, vomiting, dysphagia, pyrosis, flatulence, eructations, diarrhea, constipation, hemorrhoids, change in stool caliber, blood in stool

Genitourinary : Denies change in frequency, urgency, hesitancy, dribbling, nocturia, polyuria, oliguria, dysuria, change in urine color, incontinence, flank pain

Musculoskeletal : Denies muscle pain, joint pain, deformity, swelling, redness, arthritis

Peripheral Vascular : Denies intermittent claudication, coldness or trophic changes, varicose veins, peripheral edema, color change

Hematologic : Denies anemia, easy bruising/bleeding, lymph node enlargement, history of DVT/PE

Endocrine : Denies polyuria, polydipsia, polyphagia, heat or cold intolerance, goiter, hirsutism

Neurologic : Denies seizures, loss of consciousness, sensory disturbances, paresthesia, dysesthesia, hyperesthesia, ataxia, loss of strength, change in mental status, memory loss, asymmetric weakness

Psychiatric : Denies feelings of helplessness, feelings of hopelessness, lack of interest in usual activities, suicidal ideation, anxiety

Physical Exam :

Vital Signs :

T 36.5C

BP 168/60

P 70bpm

RR 20 breaths/min

SpO2 98%RA

General Survey : 75yo female, A/O x3. Appears upset and anxious. Mild distress.

Skin : Warm and moist, good turgor. Nonicteric. No lesions, tattoos.

Head : Normocephalic, atraumatic. Nontender to palpation throughout.

Eyes : EOMS full. No scleral icterus.

Neck : Scar on Left Neck s/p CEA. Trachea midline. No masses, lesions, scars. Supple, nontender to palpation. Full range of motion. No palpable lymphadenopathy.

Chest : Symmetrical. No deformities. No paradoxical respirations or accessory muscle use.

Respirations unlabored. LAT to AP diameter 2:1. Nontender to palpation.

Lungs : Resonant to percussion throughout. Bibasilar crackles. No wheezing, rhonchi.

Cardiovascular : S1 and S2 normal. RRR. No murmurs, gallops, rubs.

Abdomen : Soft, non-distended. Tender to direct palpation of right upper quadrant. No scars, striae, caput medusa, or abdominal pulsations. BS present in all four quadrants. No bruits over aortic/renal/iliac/femoral arteries. No masses, guarding, rebound tenderness, CVAT.

Peripheral Vascular : Extremities symmetric in color, size, and temperature. Pulses are 2+ bilaterally. No clubbing, cyanosis, or edema. No stasis changes or ulcerations.

Neurologic : AOx3. No focal deficits.

Labs :

3/26/2019, 0644

7.9

10.89> 25.2 <184

 

136 | 98 | 61 < 240

3.7  | 25 | 2.2

Mg2+: 2.3

 

19.3 | 37.0

^

2.0

 

Trop I: 0.02ng/ml

BNP: 679ng/ml (H)

 

Lipid Panel:

Total Cholesterol: 155mg/dL

Triglyceride: 143mg/dL

HDL: 44mg/dL

LDL Cholesterol Calculated: 82mg/dL

Chol/HDL Ratio: 3.52

 

eGFR Non African American: 22mL/min/1.73 (L)

 

D-Dimer: 1,144ng/ml (H)

 

Diagnostic Imaging/Procedures :

3/26/2019

EKG: Atrial-paced rhythm with prolonged AV conduction. Ventricular rate 70bpm. PR Interval 212ms. QRS duration 166ms. QTc 574ms. LVH with QRS widening.

Portable CXR: Comparison to 10/04/2017. Findings/Impression: The heart is mildly enlarged in size. The patient is status post median sternotomy. Mild pulmonary vascular congestion is noted, suggestive of congestive heart failure. No parenchymal consolidation is appreciated.

 

Assessment: PR is a 75yo female former 40 pack-year smoker with PMH significant for CAD, Paroxysmal Atrial Fibrillation, HTN, HLD, chronic combined systolic and diastolic heart failure, s/p CABG with Bioprosthetic Mitral Valve Replacement, s/p Right-sided Pacemaker, s/p stent, s/p left sided carotid endarterectomy, Anemia of Chronic Disease, Type II Diabetes Mellitus, CKD Stage IV, Hypothyroidism, Chronic Vertigo, Anxiety, and Cervical and Lumbar Spinal Stenosis, admitted with shortness of breath.

Plan:

Cardiac

#Acute on Chronic Combined Systolic and Diastolic Heart Failure

– Cont. IV Furosemide 40mg

– Consult CHF Team

– Daily weights

– Strict I&Os

– Echocardiogram. If EF <40%, consult Dr. Durban for possible upgrade to BiV AICD

– Patient is not on ACEI/ARB or Entresto due to CKD

– Case discussed with Dr. Manino

– Advised patient about the importance of daily weights, Na+ restriction, limiting fluid intake

#Elevated D-Dimer, Normal Troponin

– V/Q Scan

– Unlikely PE. INR is therapeutic. Well’s Score 0 but cannot be PERC’d out due to age.

– Serial Trop I, EKG

#PAF

– Cont. Warfarin 4mg PO one time Sat Sun Tues Thurs

– Cont. Warfarin 6mg PO one time Mon Wed Fri

#HTN

– Cont. Carvedilol 12.5mg PO bid

– Cont. Hydralazine 50mg PO tid

– Cont. Amlodipine 10mg PO qd

#HLD

– Cont. Rosuvastatin 40mg PO qd

#CAD

#s/p CABG with Bioprosthetic MVR

#s/p Right-sided Pacemaker

#s/p Stent

#s/p left sided CEA

– Cont. Aspirin 81mg PO qd

– Lifestyle modifications for CAD, HTN, HLD discussed including adopting DASH diet, the importance of regular exercise, and medication compliance

 

Hematology

#Anemia of Chronic Disease

– Scheduled for Epogen injection with Dr. Rubel today. Await Nephrology consult.

 

Metabolic

#DM2

#CKD Stage IV

– Cont. Insulin Glargine 18u qhs

– Fingerstick ac and qhs with SSI

– Nephrology consult

– Provided patient with information on DM, CKD status, and therapy targets. Discussed appropriate dietary modification, advised patient to continue fingersticks, advised patient to continue following up with ophthalmologist yearly, recommended patient to follow up with podiatry (Dr. Geoffery recommended) and the importance of diabetic foot care and regular follow ups

#Hypothyroidism

– Cont. Levothyroxine 125mcg PO qd

 

Neurology

#Chronic Vertigo

– Cont. Vestibular Rehabilitation Training

#Anxiety

– Cont. Clonazapem 0.5mg PO bid

– Cont. Sertraline 100mg PO qd

#Cervical and Lumbar Spinal Stenosis

– f/u with PMD

 

DVT Prophylaxis: Warfarin, IPC

Nutrition: Cardiac, Diabetic Diet

Dispo: Plan for >2 midnight stay

 

Case discussed with Dr. Siasoco MD who agrees with A/P.

 

/s/ Daniel DeMarco, PA-S

Physician Assistant Student