diagnostic

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).

                                                                 References

Bickley, L. S., MD, Szilagyi, P. G., MD, Hoffman, R. M., MD, & Soriano, R. P., MD. (2021). Bates guía de exploración física e historia clínica / Bates’ Guide to Physical Examination and History Taking (Spanish Edition) (13th ed.). Lippincott Williams & Wilkins.

Cash, J. C. C., Glass, C. A. G., & Mullen, J. M. (2020). Family Practice Guidelines, Fifth Edition – Complete Family Practice Primary Care Resource Book (5th ed.). Springer Publishing Company.

Drugs.com. (2021, November 24). Carvedilol. Retrieved June 11, 2022, from https://www.drugs.com/carvedilol.html

Ramahi, T. M. R. (2000). Beta Blocker Therapy for Chronic Heart Failure. American Academy of Family Physicians, 62(10), 2267–2274. https://www.aafp.org/pubs/aft/issues/2000/1115/p2267.html