CaseStudy_ of HTN, CHF/HFrEF (LVEF 20-25 %), A-FIB, and COPD
nikkyvu
CaseNoteToDo_11132024.docxThis is a 66-year-old male with a PMH of HTN, CHF/HFrEF (LVEF 20-25 %), A-FIB, and COPD, who presents for regular follow-up. In June, he experienced SOB and went to hospital. He has Exertional SOB and denies chest pain, cough, palpitation, headache, or dizziness. He did a cardiac Cath in SNH and was advised for bypass or stent. Personal Hx: smoking + 15 pieces per day for >40 yrs, alcohol occasionally, CT chest: Cath scan was done in the hospital during admission, CXR: cardia silhouette enlarged, applicable bullous in b/l lungs
PE: Cardiovascular: Normal S1 and S2, no murmurs, rubs, or gallops. Respiratory: Clear to auscultation bilaterally. Neurological: Alert and oriented to person, place, and time. No focal neurological deficits. Ophthalmologic: No papilledema was noted. ABD: soft, non-tender, Positive bowel sound in all four quadrants. Limbs: no swelling or tenderness. Preventive screening: up to date
A: Doppler: no DVT
ECHO(07/07/24):
Mild left ventricular dilatation and severely reduced left ventricular function.
Left ventricular ejection fraction estimated by 2D at 20-25 percent.
Global hypokinesis: The aortic valve is sclerotic but opens well; mild aortic valve regurgitation and mild to moderate mitral valve regurgitation.
Moderate left atrial enlargement. There is mild tricuspid valve regurgitation.
Analysis of mitral valve inflow, pulmonary vein Doppler, and tissue Doppler suggests grade III diastolic dysfunction with elevated left atrial pressures. There is no pericardial effusion.
P: Continue current medications: Atorvastatin 40 mg qhs. Eliquis 5 mg bid. Aldactone 25 mg qd. Aspirin 81 MG QD. Entresto 24/26 mg bid. Lasix 40 mg qd. Toprol xl 50 mg qd. Protonix 40 mg qd. heart rate was 108, so started on digoxin- last visit
Eliquis 5mg Tablet (take 1 tablet (5 mg) by oral route 2 times per day)
Pantoprazole Sodium 40mg Delayed-Release Tablet (take 1 tablet (40 mg) by oral route once daily)
ALDACTONE 25 MG TABLET (take 1 tablet (25 mg) by oral route once daily)
Spironolactone 25mg Tablet,
Furosemide 40mg Tablet
Atorvastatin Calcium 40mg Tablet, 30 Days;
Metoprolol Succinate 50mg Extended-Release Tablet,
DIGOXIN 125 MCG TABLET, take 1 tablet (125 mcg) by oral route once daily
Pantoprazole Sodium 40mg Delayed-Release Tablet, take 1 tablet (40 mg) by oral route once daily
ATORVASTATIN 40 MG TABLET, take 1 tablet (40 mg) by oral route once daily 30 Days;
EQL ASPIRIN 81 MG CHEWABLE TAB, chew 1 tablet (81 mg) by oral route once daily
ALDACTONE 25 MG TABLET, take 1 tablet (25 mg) by oral route once daily
Eliquis 5mg Tablet, take 1 tablet (5 mg) by oral route 2 times per day 30 Days;
ENTRESTO 24mg-26mg Tablet, 1 tab bid
LASIX 40 MG TABLET, take 1 tablet (40 mg) by oral route once daily 30 Days
follow up with a cardiologist
Intervention cardiology referral - for angioplasty
if chest pain, SOB- call 911, RTC in 2 weeks
