REASON FOR CONSULTATION: Congestive heart failure.
HISTORY OF PRESENT ILLNESS: The patient is a very pleasant (XX)-year-old male who has coronary risk factors of diabetes mellitus and hypertension with no known history of coronary artery disease or congestive heart failure. He was in his usual state of health until this morning when he woke up and had very mild shortness of breath. Subsequently, he went for a walk and after walking about a mile or so, he felt very weak and had generalized malaise. He did not have any chest pain.
At that time, he did not have any shortness of breath. He denied any diaphoresis, nausea, vomiting, palpitation, dizziness or syncope. When he was evaluated by EMS, his blood pressure was 158/70, heart rate was 96, respiratory rate 18, glucose was 204, and pulse oximetry was 96%. Subsequently, in the ED, his blood pressure was 120/68, pulse rate 88 per minute, afebrile, respiratory rate was 18, and pulse oximetry 96%. He was treated with aspirin and metoprolol. He was found to have elevated BNP and abnormal EKG. He has been admitted with congestive heart failure. He currently denies any complaints.
PAST MEDICAL HISTORY: Diabetes mellitus, hypertension. There is no history of coronary artery disease, CHF, CVA, TIA or thyroid disorder. No history of hyperlipidemia.
PAST SURGICAL HISTORY: Negative.
FAMILY HISTORY: Noncontributory.
PERSONAL/SOCIAL HISTORY: He denies any smoking, alcohol or drug abuse.
MEDICATIONS AT HOME: Included lisinopril, metformin, glipizide, and aspirin.
ALLERGIES: No known drug allergies.
REVIEW OF SYSTEMS: As mentioned above. Otherwise, denies any fever, chills, rigors or cough. No sore throat or runny nose. No orthopnea, PND or lower extremity edema. No abdominal or genitourinary complaints. No focal weakness or paresthesia of any extremities.
PHYSICAL EXAMINATION: He is alert and oriented x3, in no apparent distress. Vital Signs: His heart rate is 60 beats per minute, blood pressure 116/64 mmHg, and respiratory rate is 22 per minute. He is afebrile. HEENT: Pupils are equal, round, reactive to light and accommodation. Extraocular muscles are intact. Sclerae is anicteric. There is no oropharyngeal congestion. Neck: Supple. No JVD. Bilateral carotids are 2+. There is no bruit. No thyromegaly or lymphadenopathy. Chest: Reveals decreased breath sounds at the base with no wheezing, crackles or rhonchi. Heart: S1 and S2 normal. There is no S3 or S4. There is soft 2/6 systolic murmur at the apex with no significant radiation. Apical impulse is slightly displaced inferiorly and laterally. There is no pericardial rub. Abdomen: Soft and nontender with no organomegaly. Bowel sounds are present and normal. No pulsatile masses or bruits. Extremities: There is 1 to 2+ pitting ankle edema, bilateral distal pulse 1+ and symmetrical. Neurologically, grossly nonfocal.
DIAGNOSTIC DATA: His chest x-ray shows cardiomegaly and tortuous descending thoracic aorta but no evidence of any congestive heart failure, pneumonia or pleural effusion.
LABORATORY DATA: His BNP was greater than 1200. His CBC was within normal limits. BMP was normal except for glucose 202, BUN was 28, and creatinine 1.1. First set of CPK and troponin were negative.
His EKG done at 0830 showed normal sinus rhythm, rate 92 per minute, right bundle branch block with right ventricular hypertrophy and diffuse nonspecific ST-T abnormality, cannot exclude ischemia. As compared to the EKG from the past the ST-T changes are more prominent.
IMPRESSION:
1. This is a (XX)-year-old male who has multiple coronary risk factors, including diabetes, hypertension, and age who is presenting with weakness and malaise and has been found to have elevated BNP. Also had mild shortness of breath. His symptoms are consistent with congestive heart failure. He does have abnormal EKG with right bundle branch block, which appears to be old and he has diffuse ST-T abnormality. They are slightly prominent as compared to previous EKG from couple of years ago. He needs further evaluation to rule out underlying coronary artery disease.
2. In view of shortness of breath and weakness, we would also like to rule out possible pulmonary embolism.
3. Diabetes mellitus.
4. Hypertension.
PLAN AND RECOMMENDATIONS: We would monitor him on the telemetry. We will check serial cardiac enzymes. We agree with treating him with Lasix daily and would also continue his aspirin and ACE inhibitors. We would also put him on Lovenox 40 mg once daily for DVT prophylaxis. We will obtain an echo to evaluate LV function, assess regional wall motion abnormality. We will check a D-dimer. Further recommendations to follow.
