Daniel DeMarco                        H&P #2                                    Internal Medicine

Chief Complaint: Worsening shortness of breath

History of Present Illness:

MT is a 91yo M with 15 pack-year smoking history with PMH CAD s/p PCI LAD (1999, 2010), LCx (2005, 2015), moderate aortic stenosis, HTN, HLD, Stage 3B CKD, DM2, prostate cancer s/p radiation, bladder cancer s/p cystoscopy with biopsy (1/30/2019) admitted with progressive dyspnea on exertion x 1 week. Admits associated intermittent, non-radiating midsternal chest pain which may occur with activity or at rest. Denies fever, chills, nausea, vomiting, diaphoresis, orthopnea, PND, leg swelling.

ED course as follows. Patient had episode of bradycardia (HR 30-45bpm) associated with slight chest pressure. Patient reported relief after administration of albuterol. Stat EKG at that time did not show ischemia or infarction.

Past Medical History: CAD, moderate aortic stenosis, HTN, HLD, Stage 3B CKD, DM2, prostate cancer, bladder cancer

Past Surgical History: PCI LAD (1999, 2010), LCx (2005, 2015), Prostate Cancer Radiation, Cystoscopy and Biopsy (1/30/2019)

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

Medications: Aspirin 81mg PO qd, clopidogrel tablet 75mg PO every other day, atorvastatin tablet 40mg PO qd, atenolol tablet 25mg PO qd, amLODIPine tablet 5mg PO qd, insulin glargine 6u subcutaneous qhs, insulin lispro 0-6u subcutaneous ac, sitagliptin phosphate 100mg PO qd

Social History: Lives with wife. Former smoker, 15y, 1 pack per day, 15 pack-years. Social EtOH use. No illicit drug use.

Family History: Father, Deceased, 71yo, CAD, MI; Mother, Deceased, ?yo, Breast Cancer;

Review of Systems :

General : Admits weakness, fatigue. Denies fever, chills, night sweats, 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 : Denies headache, trauma, unconsciousness, coma, fracture, vertigo

Eyes : Denies corrective lenses, visual disturbances, fatigue, photophobia, pruritus, lacrimation, Last Eye Exam: 4/2018, Dr. Johnson

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

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

Mouth/Throat : Denies bleeding gums, sore tongue, sore throat, mouth ulcers, voice changes, dentures, Last Dental Exam: 01/2016, Dr. Leopold

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

Breast : Denies lumps, nipple discharge, pain

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

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

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 36.8C

BP 151/46

P 52 bpm

RR 18 breaths/min

SpO2 98%RA

 

General Survey : Sitting comfortably in chair. Speaking and AOx3. No apparent distress.

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

Head : Normocephalic, atraumatic. Nontender to palpation throughout.

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. Clear to auscultation bilaterally. No wheezing, rhonchi, rales.

Cardiovascular : Regular rate and rhythm. S1 and S2. Grade III/VI Crescendo-decrescendo systolic ejection murmur heard best at right upper sternal border.

Abdomen : Soft, non-distended. Non-tender to palpation throughout. 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.

Extremities/Peripheral Vascular : Extremities symmetric in color, size, and temperature. B/L groin with scar 2’ to PCI. Pulses are 2+ bilaterally. No clubbing, cyanosis, or edema. No stasis changes or ulcerations.

 

Labs :

3/31/2019

Trop <0.01

D-Dimer 1,693

BNP 177

Lipids: Total 144, Triglycerides 143, HDL 28, LDL 87, Chol/HDL ratio: 5.14

eGFR: 41 mL/min/1.73

10.8 | 23.0

^

1.0

4/1/2019

Trop <0.01

10.4

5.96> 33.5 <261

136 |103 | 32 < 201

5.0  | 24  | 1.5

Mg2+: 2.0

HbA1c: 7.5

 

Diagnostic Imaging/Procedures

1/30/2019

Bladder Biopsy Pathology: necrotic tissue with purulent exudate and scant urothelial cells with atypia

3/31/2019

CXR: Cardiomegaly. Tortuous, calcified aorta. Clear lung fields.

US Duplex B/L LE: No evidence of DVT.

V/Q Scan: Low probability of pulmonary embolus.

4/1/2019

02:42a

EKG: Sinus rhythm at 71bpm and left axis deviation with frequent PVCs in a pattern of bigeminy.

 

A/P

MT is a 91yo M with 15 pack-year smoking history with PMH CAD s/p PCI LAD (1999, 2010), LCx (2005, 2015), moderate aortic stenosis, HTN, HLD, Stage 3B CKD, DM2, prostate cancer s/p radiation, bladder cancer s/p cystoscopy with biopsy (1/30/2019) admitted with progressive dyspnea on exertion.

Cardiovascular

#Progressive Dyspnea on Exertion – Unstable Angina versus Symptomatic Aortic Stenosis

#Episode of Bradycardia

– Cont. Cardiac Monitoring

– ?Cardiac Cath versus Stress Testing – Awaiting Cardiology recs

– Consider echo to evaluate aortic valve

#CAD s/p PCI LAD (1999, 2010), LCx (2005, 2015)

#Moderate Aortic Stenosis

#HTN

#HLD

– Cont. aspirin 81mg PO qd, clopidogrel tablet 75mg PO every other day, atorvastatin tablet 40mg PO qd

– Cont. atenolol tablet 25mg PO qd, amLODIPine tablet 5mg PO qd

– Start torsemide 10mg PO qd

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

 

Metabolic

#DM2

#Stage 3B CKD

– HbA1c = 7.5

– Cont. insulin glargine 6u subcutaneous qhs

– Cont. insulin lispro 0-6u subcutaneous ac

– Hold sitagliptin phosphate 100mg PO qd

– Follow up on urine protein/creatinine, urinalysis

– Monitor BMP for electrolytes, BUN, Cr

– Appreciate nephrology recs

– Provided patient with information on A1c, 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. George recommended) and the importance of diabetic foot care and regular follow ups

#Hyperkalemia

– K+: 5.0 in the setting of CKD

– Start torsemide 10mg PO qd

– Low K+ Diet

– Monitor BMP

 

Oncologic

#Bladder Cancer – s/p Cystoscopy and Biopsy 1/30/2019)

#Prostate Cancer – s/p Radiation

– Follow up with Urology (Dr. Mathew)

– Follow up with Oncology (Dr. Liu)

 

DVT Prophylaxis: IPC. No heparin because of PMH hematuria

Nutrition: Cardiac, Diabetic, Low K+ Diet

Dispo: >2 midnight stay due to worsening SOB on exertion

 

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

 

/s/ Daniel DeMarco, PA-S

Physician Assistant Student