Download Source: patient

Source: patient
CC: "I had a brief episode of chest pain while sitting in the ophthalmology clinic."
HPI:
CM is a 65 year-old African American male with a past medical history of coronary
artery disease s/p 2 MIs (EF 45%), CHF, chronic renal insufficiency (creat 3.2),
hypertension, diabetes, and a 100 pack-year smoking history who presents to the ED after
having a brief episode of chest pain in the ophthalmology clinic. He says the pain felt
like "a person standing on my chest" and that it was a 10/10 in severity, "even worse than
then pain when I had my heart attacks." The pain did not radiate but was accompanied by
sweats, shortness of breath, rapid breathing, dizziness, weakness, and palpitations. He
describes feeling as if he were "smothering." It lasted for "about 15 seconds" after which
he felt normal again. He has had two similar episodes over the past 3 days.
Over the past 3 days he also says that he has to sleep sitting up in a chair since he
becomes short of breath when he lies down in bed. He says that he wakes up from his
chair short of breath, after which he stands up, goes to the window, and takes a few
breaths of fresh air. After "a few minutes," he is no longer short of breath and is able to
go back to his chair and sleep. This happens several times per night. He also admits to
swelling of his legs over the past 3 days. He experienced these same symptoms in 2/06
for 6 days, after which he came to the ED and was admitted to the hospital for diuresis.
He denies SOB when in an upright posture and only admits to mild SOB with exertion.
At present, he denies chest pain, SOB, and sweats. He denies fever, cough, recent upper
respiratory infection, sputum production, hemoptysis, pain on breathing, nausea, and
vomiting. The episodes are not associated with meals. He denies a history of
hyperlipidemia.
PMH:
Diabetes - 35 year history, has had diabetic neuropathy in both feet for last 4 years, also
has history of diabetic retinopathy for which he had photocoagulation earlier this year.
Sees ophthalmologist, podiatrist, and primary care doctor regularly.
HTN - 35 year history
CAD s/p 2 MIs (2003 and 2005). Cardiac caths done both times, no stents placed.
CHF
Allergies: NKDA
Medications:
furosemide 40 mg daily
lisinopril 10 mg qhs
isosorbide mononitrate 60 mg daily
hydralizine/isosorbide dinitrate 37.5/20 mg (1 tab BiDil) tid
diltiazem CD 360 mg daily
ASA 81 mg daily
amitryptaline 50 mg qhs
insulin NPH/regular 45/10 units qAM, 38/8 units qPM
FH:
Mother: age 84, has had "a couple of heart attacks," has a pacemaker, no HTN or DM
Father: DM, HTN, died at age 57 from "complications of diabetes
2 brothers: both had HTN and died of an MI at ages 40 and 25
1 sister: had HTN and died of an MI at age 53
4 children: "all healthy"
SH:
Has been married for 39 years, lives with wife, has 4 children (ages 39, 40, 42, and 44)
and 9 grandchildren. Started smoking at age 14, smoked 3-4 pack per day until "3 or 4
months ago" when he cut back to 1-2 packs per day (approximately 100 pack years). He
denies any alcohol use in the past 9 years but admits to being an alcoholic for 30 years
prior to quitting; he has been in detox 3 times. He denies any use of illicit drugs.
ROS:
General: +sweats during brief episodes as per HPI, but none currently. Denies fevers,
chills, changes in weight, fatigue.
Head: denies headache, dizziness, head injuries, syncope
Eyes: denies acute visual loss, blurry vision, flashing lights
Ears: denies tinnitus, vertigo, earache
Nose: denies stuffiness, runny nose, nosebleed
Mouth/neck: denies sore throat, hoarseness, neck swelling
Respiratory: as per HPI
Cardiac: as per HPI
GI: +constipation, but says it's due to "all the medicines I take"; uses laxatives and stool
softeners to help. Denies nausea, vomiting, diarrhea, jaundice, changes in bowel habits
or stool color, blood in stool
GU: denies frequency, urgency, hesitancy, incontinence, hematuria
Heme: denies easy bleeding, easy bruising
Endocrine: history of DM, takes insulin twice daily. Denies polyuria, polydipsia,
polyphagia, changes in appetite, heat/cold intolerance
Musculoskeletal: denies joint aches, pains, stiffness, swelling
Neuro: +parasthesias ("pins and needles") in both feet but denies numbness or pain.
Denies weakness, tremors, loss of consciousness
Psych: denies problems with sleep or mood
PE:
General: elderly male lying comfortably in bed, speaks softly and in complete sentences,
appears stated age, no acute distress, A&O x 3
VS: T 98.2 HR 93 BP 207/98 RR 18
HEENT: AT/NC, pupils 3->2 mm direct and consensual, conjunctiva noninjected, sclera
anicteric, EOMs intact, good dentition, moist mucus membranes, no oral exudates
Neck: trachea midline, no JVD, no thyromegaly, carotid pulses 2+ with no bruits
Pulm: symmetrical chest expansion, faint late inspiratory crackes at the R base, lungs
otherwise clear bilaterally
Cor: RRR, normal S1 S2, no audible m/r/g, PMI nondisplaced
Abd: soft nontender/nondistended, normal bowel sounds, no organomegaly, no flank
fullness or fluid wave.
Musculoskeletal: strength 5/5 in all extremeties, no muscle atrophy or weakness
Neurologic: CN II-XII intact, sensation grossly normal in all extremeties, reflexes 2+
(patellar, biceps, triceps, and brachioradialis)
Extremeties: Radial pulses 2+. Feet cold (compared to hands), pedal pulses nonpalpable.
1+ pitting edema in bilateral lower extremities to the mid-calf.
Data:
CBC: 6.2
9.5
29
MCV 72, RDW 15
294
Chem 7:
137
4.7
105
24
37
3.2
309
BNP 1354
Cardiac enzymes:
1st set normal (CK 229, TnI 0, CkMB 4.5)
2nd set normal (CK 202, TnI 0, CkMB 3.7)
EKG: rate 70 and regular, normal sinus rhythm, axis -11 deg (within normal range). T
wave inversion in I, aVL, V5, V6 which is unchanged since his previous EKG on 2/19.
Evidence of former inferior infarct, also on previous EKG. Borderline LVH.
CXR: residual changes of subsegmental atelectasis at R base, mild cardiomegaly
Historical data:
9/18/03
BUN
18
Creat
1.0
Hb
9.3
MCV
71
RDW
5/28/04
29
1.8
10.7
71
7/14/05
32
2.4
9.6
71
2/19/06
39
3.0
8.7
71
15.2
Echo (2/21/06): Normal LV size with mild systolic dysfunction and moderate concentric
LVH. EF 45%. Normal RV size and function. Moderate pulmonary hypertension,
PASP 56, RAP 10
Cardiac cath (7/2005): LAD proximal 40% stenosis, L circumflex proximal 30% stenosis,
RCA stable 90% stenosis distally, elevated pulmonary artery pressure 48/22
Summary: 65 year-old male with a history of coronary artery disease s/p 2 MIs, CRI,
CHF, HTN presents after an episode of chest pain, dizziness, and diaphoresis. History
notable for 3 days of orthopnea, PND, and peripheral edema. Cardiac enzymes negative
and no EKG changes.
A/P:
1. Episodic chest pain/palpitations/sweating/dizziness: He has had 3 episodes over the
past 3 days, each lasting "about 15 seconds." EKG shows no acute changes, and 2 sets of
cardiac enzymes are normal. Patient has known CAD, 2 prior MIs, and numerous risk
factors (smoking, DM, HTN, family history of premature MI). Associated symptoms of
sweats, SOB, and dizziness are consistent with a cardiac ischemic event. Absence of
EKG changes effectively rules out acute ST elevation MI. Although a non ST elevation
MI cannot be fully ruled out until the third set of cardiac enzymes comes back negative, 2
normal sets of cardiac enzymes make it unlikely. Symptoms at rest exclude stable
angina. Unstable angina is the most likely cardiac etiology, although the episode was
very brief and remitted spontaneously. Acute onset of chest pain, palpitations, sweats,
shortness of breath, dizziness, and especially a feeling of "smothering" are also consistent
with a panic attack, although again the episode was very brief. Musculoskeletal pain is
unlikely due to associated symptoms and the fact that it was not dependent on body
position. Pulmonary causes such as PE are unlikely since the pain occurs in brief,
distinct episodes, the patient denies pleuritic chest pain, and the dyspnea is better
explained by CHF. GI causes are unlikely since the pain is very brief and not associated
with meals. Plan: Follow up final set of cardiac enzymes. Repeat EKG. Continue
telemetry monitoring while inpatient. If EKG shows no changes and final set of cardiac
enzymes is negative, discharge home after treating CHF exacerbation. Follow up with
cardiology, consider stress test as outpatient.
2. CHF exacerbation: Patient has classic history of CHF, an etiology for his CHF (2 prior
MIs), evidence of systolic dysfunction on echo (EF 45%), evidence of LVH on EKG and
echo, evidence of cardiomegaly on CXR, and markedly elevated BNP. Pulmonary
hypertension is most likely secondary to CHF. Patient is currently fluid overloaded, as he
complains of orthopnea, paroxysmal nocturnal dyspnea, and peripheral edema and has 1+
pitting edema on exam. Symptoms are similar to prior CHF exacerbation in 2/06. Plan:
Diuresis with furosemide, start with 40 mg IV and increase if needed. Add beta blocker
(metoprolol 50 mg bid), since it is indicated in CHF. Have patient sit up in bed.
3. Hypertension: History of HTN, on multiple medications for HTN, initial BP in ED
was 207/98. Combination of BiDil and isosorbide mononitrate is redundant. Patient is
also not on a beta blocker despite its indication in CHF. Noncompliance with meds is
always a possibility. Plan: Continue lisinopril, BiDil, diltiazem. Stop isosorbide
mononitrate. Add metoprolol, starting at 50 mg bid. Titrate metoprolol and lisinopril to
attain recommended BP target of 130/80. Low sodium diet.
4. Chronic renal insufficiency: Patient's creatinine was normal (1.0) in 9/03 and has
gradually risen to 3.2. MDRD gives a GFR of 25.1, assuming a normal albumin (a
reduction in albumin would lower the GFR even more). This places him in the category
of stage IV renal disease. Etiology is most likely a combination of diabetic nephropathy
(especially since the patient also has neuropathy and retinopathy) and hypertension.
Anemia is also present, suggesting a deficiency of erythropoetin, although microcytic
anemia suggests another process such as iron deficiency is present as well. Plan: BP
control as above to slow progression of renal failure. Continue lisinopril, as ACE
inhibitors have been shown to be help preserve renal function in diabetic nephropathy.
Measure calcium, magnesium, and phosphate as well as UA to assess severity of
proteinuria (which is almost certainly present). Add daily calcitriol (since there is likely
decreased activation of 25-vitamin D) and calcium supplements, especially if phosphate
is high. Follow up with renal.
5. Chronic microcytic anemia: Hb has ranged from 8.7 to 10.7 from 9/03 to present,
MCV has remained consistent at 71. Differential diagnosis is iron deficiency vs.
thalassemia (alpha or beta thalassemia minor, since these are asymptomatic). High
normal RDW of 15 makes iron deficiency more likely. Epo deficiency from chronic
renal insufficiency could also be playing a role, although this would not account for the
microcytosis. Plan: Serum ferritin, iron, TIBC, transferrin saturation to test for iron
deficiency. If ferritin and iron low, TIBC high, correct iron deficiency with po iron
supplements, 325 mg tid. Consider epo administration if patient has symptoms/signs of
anemia or Hb falls below 8.0. If iron studies normal, can do Hb electrophoresis to
evaluate for thalassemia.
6. Diabetes: Patient has long-standing DM and is being treated with insulin. Blood
glucose on admission is 309, suggesting poor glycemic control, although a HbA1c level
is necessary to determine this. If HbA1c is elevated, insulin regimen may be insufficient
or patient may not be compliant. Plan: Continue outpatient insulin regimen. Finger
sticks 4x/day and sliding scale insulin as needed. HbA1c level to assess glycemic
control. Adjust insulin regimen if necessary by dividing 24-hour sliding scale corrections
between AM and PM doses.
7. Coronary artery disease: Patient has known coronary artery disease, as mentioned
above and as confirmed by cardiac cath. Plan: Continue ASA. Consider addition of
statin; even though patient does not have hyperlipidemia, some studies show that statins
have an anti-inflammatory effect.
8. Diet: cardiac, diabetic, low sodium
9. Prophylaxis: heparin 5000 units SC q 12h, PPI