neidacarobboone-editingM-80
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Valencia College *
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1611C
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Medicine
Date
Dec 6, 2023
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Uploaded by BrigadierFang12455
Internal Medicine Clinic Followup
Patient Name
: James Sebastian Wright
PCP
: Sherman Loyd, MD
Date of Exam
: 16 March
----
Age/Sex
: 77-year-old male
ID#
: M-80
REASON FOR VISIT
: Follow up of sleep study and echocardiogram.
HISTORY OF PRESENT ILLNESS
:
Mr. Wright is a pleasant 77-year-old white
gentleman with a past medical history significant for chronic abstracted
pulmonary disease and asthma, restrictive lung disease secondary to
significant scoliosis, Barrett esophagus, hypertension, and a history of
prostate cancer. Patient reports an approximately 6-month history of
increased dyspnea on exertion. He also has been noticeably tachycardic in
the high 90s to low 100s at each visit for 2 years. EKG done at our last visit
showed only sinus tachycardia at 101 beats per minute. Given his
underlining pulmonary disease, I have had concern for right heart strain from
pulmonary hypertension. I referred patient to a cardiologist. He was deferred
to the network. He had an echocardiogram done that showed a normal left
ventricle with mild left ventricular systolic dysfunction with an ejection
fraction of 40%. He had a follow up nuclear perfusion study that showed an
ejection fraction of 48% with no significant ischemia. There was no comment
on an estimated pulmonary artery pressure. Patient was also started on
lisinopril 10 mg daily for his blood pressure. He has done well with the
addition of this medication. Patient has had a sleep study done since our last
visit by Dr. Gatlin of Pulmonology. The sleep study revealed sleep apnea with
abnormal ocean desaturation, snoring, hypertension, and cardiac arrhythmia
with fragmented sleep. It was recommended that he start nasal CPAP at 15
cm of water. Patient states that he received the equipment last week but has
not yet begun using it.
CURRENT MEDICATIONS
1.
Aspirin 81 mg daily.
2.
Mock side 25 mg daily.
3.
Lisinopril 10 mg daily.
4.
Zocor 10 mg daily.
5.
Singulair 10 mg daily
6.
Tylenol p.r.n.
7.
Os-Cal Plus D b.i.d.
8.
Prevacid 30 mg daily.
9.
Patanol eye drops p.r.n
Internal Medicine Clinic Follow up.
Patient Name: James Sebastian Wright
Date of Exam: 16 March ----
ID#: M-80
Page 3
10. Flonase daily.
11. Detrol LA 4 mg h.s.
12. Combivent 2 puffs t.i.d.
13. Flovent 200 20 mcg b.i.d.
PHYSICAL EXAMINATION
: Blood pressure is 127/77, pause 108,
respirations 16, temperature 98.9, height 72 inches, and weight 139 kg. In
general he is an obese gentleman with significant keeper scoliosis. HEENT:
Unremarkable. NECK: Supple without bruits. CARDIOVASCULAR: Regular rate
and rhythm. Normal S1, S2. No S3 or S4. No murmurs. CHEST: Clear to
auscultation bilaterally. EXTREMITIES: No cyanosis, clubbing, or edema.
BACK: Patient has an area on his right lower back consistent with folliculitis.
LABORATORY DATA
: On 13 March white blood cells were 6.2, hemoglobin
14, hematocrit 14.7, and platelets 212,000. TSH 1.48, glucose 102, BUN 31,
creatinine 1, sodium 139, potassium 4.4, magnesium 2.1.
ASSESSMENT
: 77-year-old white gentleman with past medical history as
listed above with the new findings of obstructive sleep apnea and mildly
depressed ejection fraction of unclear etiology as well as persistent sinus
tachycardia.
PLAN
1.
Sinus tachycardia: Patient has had a 6-minute walk in the Pulmonary
Clinic and shows no evidence of hypoxemia with ambulation. He does
have significant nighttime oxygen desaturation, and where beginning
CPAP to treat this. Again, given patient's body habitus and underlying lung
disease, I am concerned that he is having right heart strain from
pulmonary hypertension. I will try to contact the clinic where he had his
echocardiogram done and see if they are able to estimate his pulmonary
artery pressures before trying to refer him for another study. In the
meantime, he also may be somewhat volume depleted, given his use of
Maxzide and his increased BUN. Will have patient discontinue Maxzide
and begin hydrochlorothiazide 12.5 mg daily. He is to have a followup
camp panel in approximately 1 week.
Internal Medicine Clinic Follow up.
Patient Name: James Sebastian Wright
Date of Exam: 16 March ----
ID#: M-80
Page 4
2.
Hypertension: Well controlled with use of lisinopril and Maxzide. Will
continue lisinopril and change Maxzide to hydrochlorothiazide 12.5 mg as
discussed above.
3.
Mildly depressed ejection fraction: Patient with no evidence of ischemia on
nuclear perfusion testing. He has also been asymptomatic other than the
dyspnea on exertion, which may be related to tachycardia. His ejection
fraction actually may be depressed secondary to his signs of tachycardia.
Will continue to investigate the sinus tachycardia and pursue further
ischemic evaluation as appropriate at a later date.
4.
Obstructive sleep apnea: Patient is to begin using nasal CPAP on a regular
basis. He is to call or notify me if he has difficulty tolerating this.
5.
Barrett esophagus: Patient is to continue his Prevacid as listed above. He
is up to date on his screaming.
6.
Health care maintenance is up to date.
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DISPOSITION
: Patient is to follow up with me in 4 to 6 weeks, sooner as
needed.
____________________________________
Dr. Michael Panagides, MD, Internal Medicine
MP:ncb
D: 3/l6/----
T: 3/l7/----
c:
Joshua Stephen Gatlin, MD, Pulmonology, Saul Thompson, MD, Cardiology,
Sherman Loyd, MD, Internal Medicine