Identifying Data:
Full Name: J.A.
Age: 83
Sex: Male
Marital Status: Widowed
Race/Nationality: Indian
Address: Queens, NY
Date of Birth: XX/XX/1938
Date and Time: 10/05/2021 9:30 AM
Location: New York Presbyterian Hospital Queens
Religion: Hindu
Source of Information: Self
Source of Referral: Self
Reliability: Reliable
Mode of Transport: private vehicle
Chief Complaint: shortness of breath x 2 days
History of Present Illness:
83-year-old male, with a PMHx of T2DM, HTN, HLD, CAD, CKD, hypothyroid, BPH, CHF, who presented to the emergency department with shortness of breath that started last night. Patient reports the shortness of breath is worse with exertion and lying flat. He states it feels similar to his previous CHF exacerbations. Patient was seen at another hospital yesterday for similar symptoms and was treated with IV Lasix 80mg and discharged home. Patient came to NYPQ because he felt his symptoms were not improving. He denies fever, chills, chest pain, cough, sputum production, nausea, vomiting, diarrhea, or abdominal pain. He denies a history of COPD or smoking. He denies any sick contacts.
In the ED, the patient was hypoxic to 90% on room air with otherwise stable vitals. Troponin of 1.8 and BNP of 48,000. CXR showed moderate vascular congestion. Patient was treated with IV Lasix 60 mg. Patient was admitted to medicine for further management of acute on chronic CHF exacerbation.
Patient is currently resting in his chair in no acute distress with 2L nasal cannula. He denies any symptoms or any overnight events. Patient is pending vascular and podiatry consults for his lower extremities. Labs unchanged from previous. Will continue IV Lasix. Patient has surgery scheduled for 10/14 for AICD placement, as patient previously refused AICD placement. Patient will be discharged tomorrow with home oxygen with humidifier and PO Lasix.
Past Medical History:
- Present illnesses:
- Chronic Kidney Disease Stage IV
- Type 2 Diabetes Mellitus
- Hypertension
- Benign Prostatic Hypertrophy
- Congestive Heart Failure
- Hyperlipidemia
- Hypothyroidism
- Coronary Artery Disease
Past Surgical History:
- Stent placement in 1999 and 2018
Family History:
- Non-contributory family history
Medications:
- Pregabalin 25 mg daily PO
- Pantoprazole 40 mg daily 30 mins before breakfast PO
- Nortriptyline 10 mg daily PO
- Metoprolol succinate ER 25 mg daily PO
- Levothyroxine 100 mcg daily early morning PO
- Insulin lispro injection 4 units subcutaneous three times a day
- Insulin glargine 12 units subcutaneous 0.2 units/kg nightly
- Finasteride 5 mg daily PO
- Clopidogrel 75 mg daily PO
- Atorvastatin 40 mg PO once daily
Allergies:
- Januvia (Sitagliptin) – hives
- Denies any other food, medication, or environmental allergies.
Social history:
- Widowed, lives with alone with 24/7 home health aide in private home.
- Retired cardiologist. Supported by pension and family.
- Habits: Denies present or past tobacco use, alcohol use or illicit drug use.
- Recent travel: Denies
- Diet: Healthy diet
- Exercise: Denies
- Sleep: Reports to sleeping seven hours a night.
- Sexual history: Denies being currently sexually active, formerly with one female partner.
Review of Systems:
General: Admits to weakness and fatigue. Denies fever, chills, night sweats, decreased appetite, weight gain/weight loss.
Skin, hair, nails: Admits to skin discoloration and ulcers on bilateral lower extremities. Denies changes in texture, excessive dryness or sweating, pruritis or changes in hair distribution.
Head: Denies headache, dizziness, or head trauma.
Eyes: Denies blurry vision, double vision, loss of vision, photophobia, pruritus, or lacrimation.
Ears: Denies hearing loss, discharge, tinnitus, ear pain or use of hearing aids.
Nose/Sinuses: Denies nasal congestion, nasal discharge, sinus pressure/pain, or loss of smell.
Mouth/throat: Denies bleeding gums, mouth ulcers, sore throat, voice changes or use of dentures. Last dental exam unknown.
Neck: Denies localized swelling/lumps or stiffness/decreased range of motion.
Respiratory: Admits to shortness of breath. Denies cough, wheezing, sputum production.
Cardiovascular: Admits to leg edema. Denies palpitations, chest pain, hypertension, irregular heartbeat, syncope or known heart murmur.
Gastrointestinal: Denies abdominal pain, abdominal distention, nausea vomiting, hematemesis, diarrhea, constipation, hemorrhoids, rectal bleeding. Last colonoscopy unknown.
Genitourinary: Denies dysuria, hematuria, hesitancy, flank pain, nocturia, oliguria, polyuria, frequency, urgency, incontinence.
Musculoskeletal: Denies muscle or joint pain, back pain, redness, stiffness, unsteady gait, or deformities.
Peripheral vascular exam: Admits to peripheral edema and color changes. Denies intermittent claudication, coldness, varicose veins.
Hematologic: Denies anemia, easy bruising or bleeding, lymph node enlargement, blood transfusions or a history of DVT/PE.
Neurologic: Denies dizziness, lightheadedness, headaches, sensory disturbances, changes in cognition/memory, LOC, loss of strength, ataxia, or numbness.
Psychiatric/Behavioral: Denies sleep disturbance, depression, suicidal ideations or seeing a mental health professional.
Physical Exam:
VS: T 97.9 F, BP 93/53, HR 80 bpm, RR 14 unlabored, O2 sat 92% on 2L NC, Ht 1.626 m, Wt 61.2 kg, BMI 23.1
Gen: Awake, alert, and oriented, in no acute distress. Frail appearing.
Skin: Warm and moist, no rash, bruises, or pallor. Normal skin turgor. Non-icteric skin. Skin discoloration to bilateral lower extremities. Bilateral lateral malleolus ulcers with no surrounding edema, erythema or drainage. Mild tenderness to palpation of lower extremities bilaterally.
Head: Normocephalic, atraumatic.
Eyes: Symmetric OU. No eyelid swelling, ptosis or lesions. Sclera non-icteric. PERRLA. EOMI.
ENT: Mucous membranes moist. No erythema or exudates in oropharynx. Uvula midline. Trachea midline, thyroid non-enlarged. No lymphadenopathy. Nasal canula in place.
Cardiovascular: Regular rate and rhythm. S1 and S2 with no murmurs. Radial pulses, DP/PT pulses 2+ bilaterally. Capillary refill less than 2 seconds bilaterally. +2 pitting edema to bilateral lower extremities up to the ankle. JVD. No carotid bruits.
Respiratory: Crackles at bilateral bases. Speaking in full sentences.
Abdomen: Bowel sounds present in all quadrants. Soft, nontender, nondistended with no rebound or guarding.
Extremities: Full range of motion of all extremities. Strength grossly intact. No ecchymosis, atrophy, or deformities.
Neuro: Alert and oriented to person, place, and time. No focal neurological deficit.
Differentials:
- CHF exacerbation
- Acute kidney injury on Chronic kidney disease
- Pneumonia
- Myocardial infarction
Labs as of 10/5:
- CBC
- WBC: 4.75
- Hemoglobin: 9.5
- Hematocrit: 30.6
- MCV: 89.2
- MCH: 27.7
- MCHC: 31
- RDW: 19.2
- Platelets: 119
- BMP
- Sodium: 144
- Potassium: 3.9
- Chloride: 103
- BUN: 95.6
- Creatinine: 3.59 (baseline 3.1)
- Glucose: 110
- Live function panel from 10/1:
- Alk phos: 102
- AST: 24
- ALT: 18
- Protein total: 6.8
- Albumin: 3.3
- Globulin: 3.5
- Bilirubin: 0.5
- Direct bilirubin: 0.2
- Indirect bilirubin: 0.3
- PTT: 16.1
- INR: 1.4
- Lipase: 43
- Troponin 10/1: 1.700 6 hours later 1.610 1.880, 10/2: 1.780
- BNP: 48,314 pg/mL
- Magnesium: 1.6
- Folate: > 20
- Vitamin B12: 896
- Ferr: 183
- Iron: 35
- Transferrin: 164
- TIBC: 213
- Iron saturation: 16
- Urinalysis
- Color: Yellow
- Appearance: Clear
- Glucose: negative
- Bilirubin: negative
- Ketones: negative
- Nitrites: negative
- Leukocyte esterase: negative
- Bacteria: negative
- Gravity: 1.011
- WBC: 1
- RBC: 2
- Squamous epithelial cells: 1
- Hyaline cast: 3
- Blood: small
- pH: 5.5
- Protein: 30
- Urobilinogen: 0.2
In: 100 mL
Out: 830 mL urine
- SARS-CoV-2-NAAT: negative
EKG:
- Normal sinus rhythm at 78 bpm with no ST elevations or T wave inversions. Left bundle branch block. Unchanged from prior EKG.
Imaging:
- TTE 10/1: No significant change from 6/29/21. Left ventricular systolic function severely reduced. Ejection fraction based on measurement and visual is less than 20%. No obvious left ventricular thrombus. Right ventricle dilated with reduced systolic function. No significant pericardial effusion. Left pleural effusion present.
- CXR 10/5: Stable bilateral opacities obstructing hemidiaphragm and costophrenic angles and mildly prominent interstitial opacities suggesting congestion. No pneumothorax.
- CT Chest 10/5: Bilateral pleural effusions, right greater than left. No interstitial prominence to suggest congestion, excluding effusion. Moderate cardiomegaly. Scattered atelectasis.
- ABI/PVR LE: Normal bilateral lower extremity perfusion to ankles. Evidence of mild inframalleolar arterial occlusive disease affecting bilateral lower extremities.
Assessment/Plan:
83 y/o male with a PMHx of T2DM, HTN, HLD, CAD, CKD, hypothyroid, BPH, CHF, presenting for shortness of breath. Patient was admitted to medicine. Labs/imaging consistent with CHF exacerbation.
- Acute on Chronic CHF Exacerbation
- Hypoxic to 88-90% on room air. Saturating well on 2L nasal canula
- Troponin 1.7, likely secondary to CKD, but will trend to peak
- BNP 48,000
- EKG in ED with left bundle branch block, no change from prior
- CXR in ED showed moderate pulmonary vasculature congestion
- Echo with ejection fraction less than 20%
- IV Lasix 60 mg twice daily
- Continue to keep potassium over than 4 and magnesium over 2
- Continuing to monitor on telemetry with planned discharge for tomorrow
- Acute kidney injury on chronic kidney disease
- Creatinine 3.24 on admission, baseline around 3.0
- Nephrology consult appreciated, will continue Lasix and avoid additional nephrotoxins
- Will continue to monitor BMP, urinary output
- Lower extremity ulcers
- Infectious disease requested vascular and podiatry consults, pending
- Hypertension
- Continue metoprolol succinate ER 25mg daily PO
- Blood pressure has remained stable
- Hyperlipidemia
- Continue with atorvastatin 40 mg PO once daily
- Coronary artery disease
- Continue with Plavix 75 mg daily PO
- Diabetes mellitus
- Continue with insulin
- Insulin lispro injection 4 units subcutaneous three times a day
- Insulin glargine 12 units subcutaneous 0.2 units/kg nightly
- Monitor blood glucose
- Continue with insulin
- Diabetic neuropathy
- Continue with Pregabalin 25 mg daily PO
- BPH
- Continue with finasteride 5 mg daily PO
- Hypothyroidism
- Continue with Synthroid 100 mcg daily every morning PO
- GI prophylaxis
- Continue with Protonix 40 mg PO
- DVT prophylaxis
- Continue with subcutaneous heparin 5,000 units q8hours SC