Group Diagnostic Workup Assignment: Congestive Heart Failure 2
ID:
M. R., 51-year-old, Caucasian male, who appears to be a good historian, came alone to the clinic.
CC:
“I feel short of breath when I walk.”
HPI:
Patient states the shortness of breath has been worsening over the last month. Patient is obese with a BMI of 34, no discoloration noted, patient is tachypneic walking from lobby to exam room, relieved upon rest.
PAST MEDICAL HISTORY:
Chicken pox
HTN
Diabetes
Insomnia
Low back pain
SURGICAL HISTORY:
Vasectomy
IMMUNIZATIONS:
Current on childhood vaccinations
Last TDAP approximately 4 years ago
Yearly Influenza
Declined COVID vaccine
CURRENT MEDICATIONS/OTC’S:
Lisinopril 10mg daily
Metformin 1000mg TID with meals
Patient reports daily use of supplements as listed:
Vitamin A, B12, B6, C, D, E
Calcium
Magnesium
Fish oil
Probiotics
ALLERGIES:
NKA
FAMILY HISTORY:
MGM: Smoker/Lung Cancer
MU: Substance abuse/alcohol/death
FA: Substance abuse/alcohol/drugs/death
SOCIAL HISTORY:
Patient reports he drinks approximately 5-7 alcoholic beverages weekly
Smokes cigars once every 14 days
Occasional use of edible marijuana for sleep, reports less than 3 times a week
Exercises approximately 20 minutes 2 days a week, walking
Coffee daily 2-3 cups
Bank Teller
Married
Lives in a Home without stairs
Reports diet of primarily chicken, fish, eggs, and vegetables
SEXUAL/REPRODUCTIVE HISTORY:
Patient reports one sexual partner for the last 6 years
Past history of condom use when multiple partners
Currently no use of condoms or other preventative measures
No difficulty getting/maintaining an erection
Vasectomy
REVIEW OF SYSTEMS:
Constitutional: No generalized weakness or body aches, denies fevers or chills
Skin: denies rash
HENT: Denies headache, sore throat, and ear pain
Eyes: denies double vision, no blurred vision
Cardiovascular: denies chest pain, reports shortness of breath when walking, reports swelling to legs
Respiratory: Reports shortness of breath when walking, feels it is difficult to breathe when active
Gastrointestinal: denies abdominal pain, regular bowel movements
Genitourinary: denies difficulty urinating
Musculoskeletal: denies muscle pain, reports swelling to bilateral legs
Endo: denies polydypsia, denies increased urination
Lymph: denies lumps in neck, axillary, or groin
Heme/Allergies: Negative. Patient reports does not bruise easily
Neurological: No tingling/numbness, denies dizziness
Psychiatric/Behavioral: denies psychiatric symptoms
Please refer to my history of present illness for any other pertinent information
Objective:
Physical Exam:
BP: 154/98 mmHg
HR: 98 bpm
RR: 26 bpm
02 sat: 95% on room air
T: 98.6
Pain: denies
Height: 74”
Weight: 265 lbs
BMI: 34
Obese
General Survey: Patient is alert and oriented x4, appears pleasant, good eye contact, patient is tachypneic upon initial contact following ambulation from lobby to exam room, reduced to non-labored respiratory rate after approximately 10 minutes at rest.
Eyes: Clear, red reflex present, 20/20 vision in left, right, and both eyes (cranial nerve II, intact) when tested with snellen chart. No discharge, swelling, or erythema noted. Eyes are PERRLA. All extra-ocular movement is intact, cranial nerve III, oculomotor, IV, trochlear, and VI, abducens nerves are intact, no nystagmus noted.
Ears, Nose, Throat: Tympanic membrane easily viewed, pearly gray, cone of light in normal anatomical position, unable to visualize bones through tympanic membrane, no fluid visualized through tympanic membrane. Patient with greater air conduction to bone conduction as tested through Rinne test, equal bone conduction as seen through Weber test. Nose is healthy with no swelling or redness noted in the turbines, throat is pink, moist, uvula rises with vocal “aaaaaa” sound, cranial nerve X, vagus nerve, is intact. Tonsils noted intact with no redness or swelling.
Cardiovascular: S1/S2 present, no audible murmurs, no bruits noted in the carotids. Jugular distention seen when placed in 30-45 degree reclining position. No abnormalities seen in visual inspection of chest wall. Capillary refill <3 seconds, no cyanosis. No detected/audible heart murmurs over aortic, pulmonic, ERB’s point, tricuspid, or mitral valves noted. Shortness of breath reported upon activity, +3 edema in bilateral lower extremities.
Respiratory: Patient with crackles bilaterally. No clubbing or discoloration of the nails. Patient with even and symmetrical chest expansion, no barrel chest noted. Shortness of breath with activity improves with rest.
Gastrointestinal: Abdomen appears rounded,symmetrical, non-distended, with normal coloration, normal hair dispersion. Bowel sounds present in all four quadrants, normoactive. Patient denies any pain upon palpation, no rebound tenderness, negative murphy’s sign. Patient liver measured via percussion is 6cm at mid clavicular line. No abdominal distention or discoloration visualized.
Genitourinary: Patient denies any dysuria, blood in urine, or foul odors. Patient is sexually active, in a long term monogamous relationship, visual examination of genitalia is all WNL.
Musculoskeletal: Patient is with full range of motion, no pain upon palpation, strength in all areas strong.
Integumentary/Breast: No noted, lesions, abrasions, rashes, or bruising. Normal, no discharge from breasts/nipples.
Neurologic: Patient is alert and oriented x4, all cranial nerves are intact. No tingling, numbness, or alteration in sensation. Smell intact and taste are intact, no dizziness. Patient reports fatigue x 1 month.
Psychiatric: Patient is smiling, good eye contact, and plans for the future. Patient is hopeful and has plans for the future. Patient reports stress at work, due to difficulty standing and walking without feeling short of breath and fatigued.
Hematologic/Lymphatic: No noted bruises, bleeding, no swollen lymph nodes noted.
Endocrine: Patient denies any excessive thirst or urination. Skin is not dry/flaky.
Allergic/Immunologic: Patient states no seasonal allergies.
Differential Diagnosis:
Heart failure
COPD
Asthma
Tests for diagnosis:
Echocardiogram
Chest x-ray
Labs (BNP, CBC, CMP, Cholesterol)
EKG
Final Diagnosis:
Congestive Heart Failure, class II
r/t:
Echocardiogram results of EF less than or equal to 40%
BNP greater than 100 pg/mL
CXR showing cardiomegaly
Edema and weight gain
hx of HTN
Plan:
Add beta-blocker and continue ACEI (Cash et al., 2020).
*Continue Lisinopril 10mg daily PO
*Start Carvedilol 45mg daily PO (Drugs.com, 2021)
Weight loss
Exercise regimen
Education:
Weigh yourself daily at the same time, same clothing, same scale, call MD if weight gain greater than 3lbs (Cash et al., 2020).
Take heart rate and blood pressure prior to taking blood pressure medication, hold if SBP less than 100mmHg, hold propranolol if Heart rate less than 60bpm.
NSAIDS are not recommended for patients with HF, do not start any OTC medications without speaking to your provider (Cash et al., 2020).
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