ar old Asian male presents to your clinic for a follow-up appointment. He is c/o dyspnea. SOB has gradually increased over the last 4 days and is worse when lying down in bed. He cannot walk more than 25 feet without SOB. He sleeps downstairs in a recliner, mostly so he doesn’t have to go up the stairs. He denies fever, chills, chest pain, palpitations, dizziness constipation, diarrhea, abdominal pain, or nausea. Reports 7 kg weight gain over the past week, chronic nonproductive cough. PmHx: heart failure, DM type II, HTN, CAD, MI, CKD FHx: Father died of MVC at age 62, mother died of heart failure at age 79, sister (age 65, alive) with HTN SHx: never used tobacco, etoh 1-2 drinks/month, retired, married with 1 daughter (ages 41, healthy), used to walk at the neighborhood track, but can’t anymore; eats mostly fish and vegetables, does not use salt. Meds: carvedilol 3.125mg BID li
Case study
HPI: 73 year old Asian male presents to your clinic for a follow-up appointment. He is c/o dyspnea. SOB has gradually increased over the last 4 days and is worse when lying down in bed. He cannot walk more than 25 feet without SOB. He sleeps downstairs in a recliner, mostly so he doesn’t have to go up the stairs. He denies fever, chills, chest pain, palpitations, dizziness constipation, diarrhea, abdominal pain, or nausea. Reports 7 kg weight gain over the past week, chronic nonproductive cough.
PmHx: heart failure, DM type II, HTN, CAD, MI, CKD
FHx: Father died of MVC at age 62, mother died of heart failure at age 79, sister (age 65, alive) with HTN
SHx: never used tobacco, etoh 1-2 drinks/month, retired, married with 1 daughter (ages 41, healthy), used to walk at the neighborhood track, but can’t anymore; eats mostly fish and vegetables, does not use salt.
Meds: carvedilol 3.125mg BID lisinopril 40mg daily
furosemide 40mg BID glimepiride 2mg daily
potassium chloride 20 mEq daily atorvastatin 40 mg daily
ASA 81 mg daily
Vital Signs: BP = 132/84 HR = 76 RR = 22 Ht = 6’2” Wt = 100 kg
Physical Exam: no abnormalities except moderate respiratory distress, cool, pale skin, mild diaphoresis, +JVD (7cm at 30°), crackles bilaterally, displaced PMI, 3+ pitting edema in ankles
Labs:
|
Na 135-145 |
132 |
Hgb 13-17 |
13 |
AST (SGOT) is about 5 to 40 units per |
34 |
|
K 3.5-4 |
3.2 |
Hct 39-51 |
40 |
ALT 10-54 |
27 |
|
BUN 9-24mg/dl |
32 |
A1c < 5.7 |
6.1 |
|
|
|
Creatinine 0.73-1.22mg/dL |
2.3 |
BNP <100 |
776 |
Mg 1.7-2.3 |
1.9 |
|
Glucose |
124 |
|
|
|
|
- Are there any other appropriate diagnostics, lab work, or follow-ups you would like to order for this patient?
Chest X ray
CT
Blood work NT-proBNP
Echo 2D
Weight daily
Pulmonary consult
- What teaching/counseling would you stress for this patient and why?
Fluid restriction
Incentive spirometer
Nutrition
Taking medication in time.
Please give me your feedback.
Thank you
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