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History and Physical and Labs CC: End-stage nonischemic cardiomyopathy HPI: RM is a 55-year-old woman who presents with a history of nonischemic cardiomyopathy that was diagnosed 8 years ago. Despite maximal medical therapy she has experienced a chronically decompensating course and was placed on the heart transplant list. She reports shortness of breath at rest that is exacerbated by even mild activity, such as walking to the bathroom. She has to elevate her head with five pillows in order to sleep, because this makes her feel less congested and eases her breathing when reclining. Nonetheless she awakens every night after 2-3 hours with severe breathlessness. She also complains of increased urinary frequency at night and episodes of coughing up bright red blood. PMH: RM reports no other major health problems. Meds: The patient is on various medications, including diuretics and inotropic drugs. Allergies: RM reports no known allergies. FH: The family history is unremarkable. SH: RM denies any history of alcohol, tobacco or illicit drugs. RM is married and lives with her husband. She has three adult children, two of which live close by. Physical Exam: VS: T= 97.2 HR=100 RR=21 BP=100/70 O2 sat 90 % on 4 L O2 General: patient is short of breath and diaphoretic (sweaty). She appears frail and wasted. HEENT: pupils equal, round and reactive to light and accommodation, extra-ocular muscles intact, oropharynx moist and pink with no exudates Skin: peripheral pallor Neck: no lymphadenopathy, 5cm jugular venous distension, no thyromegaly, no bruits Cardiac: tachycardia, loud P2, S3 gallop Respiratory: bilateral wheezes and rhonchi, most pronounced over lung bases Abdomen: tender in right upper quadrant, hepatomegaly, no abdominal bruits, +bowel sounds, Extremities: cold to touch, 3+ edema in presacral region, ankles and feet (0-4 scale; 0 is normal), pulses weak Neuro: alert & oriented x3; cranial nerves II-XII intact, sensation to light touch and proprioception grossly intact on toes and fingers, range of motion of upper and lower extremities is normal, muscular strength 4/5 in upper and lower extremities, 2+ Achilles, patellar, biceps, triceps reflexes (0-4 scale; 2+ is normal), toes downgoing, finger-tonose intact, heel-to-shin intact, normal gait but fatigues easily. Laboratory results: Summarize the following findings: Abnormal liver and kidney function?? Diagnostic x-ray: Cardiomegaly, pleural effusions, hazy hilar shadows Angiograms? Echocardiography ? ECG ?
