Ms W. is a 65 year old Caucasian female who is presenting to the hospital after 3 weeks of progressively worsening shortness of breath. She has a previous medical history of obstructive sleep apnea, arthritis (s/p right knee replacement in 2010), hypertension, and depression. She reports that there have been no recent changes in her life in the past few weeks, except that her CPAP machine broke about four weeks ago. She has 3 young grandchildren in the area, who keep her active. She will walk or bike with them to the playground, and even take them to a pool to swim. She also walks her dog about half a mile every evening. She reports that about 3 weeks ago she had a mild cold. Her cough and nasal drainage resolved fairly quickly, but her shortness of breath, especially with any activity slowly got worse. Today, she reports even walking a few steps will cause her to be short of breath.
Past medical/surgical history:
Arthritis – right knee replacement 2010
Sleep apnea and CPAP dependent
Hypertension
Depression
Allergies:
Penicillin – unknown reaction
Hydrocodone – nausea
Morphine – hallucinations
Environmental pollen allergies
Home medications:
Aspirin 81 mg daily PO CAD prophylaxis
Ibuprofen 400 mg every 6 hours as needed for joint pain
Lisinopril 10 mg daily for hypertension
Citalopram 40 mg daily for depression/anxiety
Fluticasone 50 mcg/ACT nasal spray 2 times a day for seasonal allergies
St John’s wort daily for depression
Multivitamin daily
Social and Family History:
No family medical history on file.
Married to spouse for 37 years; 3 children, 5 grandkids
Education/work: Now retired. Worked with spouse at auto repair shop, and raised 3 children.
Smoking status: former smoker for 20 years; quit at age 40
Alcohol: 1 -2 drinks daily; wine and mixed drinks
Illicit drug use: none reported
Sexual activity: one partner (spouse) since marriage
Review of systems:
Constitutional: Positive for shortness of breath, fatigue, malaise. Negative for chills, diaphoresis and fever.
HENT: Negative for headache, sore throat, nasal drainage
Eyes: Negative for blurred vision and photophobia
Respiratory: Positive for shortness of breath on exertion and waking from sleep. Negative for cough, sputum production and wheezing.
Cardiovascular: Positive for orthopnea and bilateral lower extremity leg swelling. Negative for chest pain or palpitations.
Gastrointestinal: Positive for abdominal pain/pressure, constipation, bloating, and mild nausea. Negative for diarrhea, heartburn, and vomiting.
Genitourinary: Negative for dysuria and frequency
Musculoskeletal: Positive for joint pain (left knee, both ankles). Negative for myalgias.
Skin: Positive for itchy rash on right calf, negative for bruising or open lesions
Neurological: Positive for lightheadedness with exertion. Negative for focal weakness, headaches, or syncope.
Endo/Heme/allergies: No easy bruising. No anaphylaxis episodes.
Mental health: Positive for chronic depression, and acute anxiety. Negative for suicide attempts.
Vitals:
Height 5’5’’(65”), weight 170 pounds (77.3kg), temp 37.4˚C (99˚F), Blood pressure 90/50 mmHg, pulse 45 beats per minute, respiration 25 breaths per minute at rest, oxygen saturation 88% on room air.
Physical exam:
Constitutional: Oriented to person, place and time. Appears well-developed and well nourished.
HENT: Head: normocephalic and atraumatic. Mouth/Throat: No oropharyngeal exudate. Eyes: conjunctivae and EOM are normal. Pupils are equal, round, and reactive to light. No scleral icterus. Neck: normal range of motion. Neck supple. JVP 6 cm above sternal angle.
Cardiovascular: Regular rhythm, S1, S2 and S3 heart sounds present. No gallop. Positive for friction rub. No murmur appreciated.
Pulmonary/chest: Respiration rate regular; diminished breath sounds in bases. No wheezes or rales. No rhonchi.
Abdominal: Hypoactive bowel sounds; distention present. Not tender to palpation; no rebound or guarding. Liver palpable with smooth edges.
Musculoskeletal: Normal range of motion. +1 bilateral lower extremity edema to ankles.
Neurological: No cranial nerve deficit appreciated
Skin: warm and dry. No bruising noted. No diaphoresis. Positive for quarter size raised red rash on right posterior calf.
Psychiatric: Attentive and able to carry on appropriate conversation. Seems anxious about being in hospital.
Imaging data:
Chest x-ray:
Positive for pulmonary edema bilaterally and atelectasis. Positive for cardiomegaly. No evidence of pleural effusions. No comparison exam available.
Electrocardiogram data:
12 lead EKG (now): sinus bradycardia with 1st degree AV block, right bundle branch block
Holter monitor conclusion (last week): Sinus rhythm. No AV block. No pauses more than 2 seconds. Rare-occasional supraventricular ectopic beats. Five SVT runs (rate over 100 bpm). Occasional-frequent ventricular ectopic beats.
Labs at admission:
| Sodium | 143mEq/L |
| Potassium | 6.3 mEq/L |
| Chloride | 106 mEq/L |
| CO2 | 23 mEq/L |
| BUN | 21 mg/dL |
| Creatinine | 1.09 mg/dL |
| Glucose | 98 mg/dL |
| Calcium | 8.5 mg/dL |
| Magnesium | 1.8 mEq/L |
| Albumin | 3.5 g/dL |
| AST | 108 U/L |
| ALT | 83U/L |
| Bilirubin, Total | 0.4 mg/dL |
| WBC | 12.0 thousand/mm3 |
| Hematocrit | 33% |
| Platelets | 152 thousand/mm3 |
| Troponin T | 4.32 ng/mL |
Admission orders:
Admit to hospital, continuous telemetry, bedrest, NPO, ECHO, left heart catheterization, cardiac MRI, pulmonary function tests, Labs: BNP, d-dimer, lyme titer, CRP. Basic metabolic panel, complete blood count
Medications: metoprolol 25 mg PO daily, alprazolam 0.25 mg PO every 6 hours PRN for anxiety, CPAP at night, 1 – 6 L O2 nasal cannula (titrate for O2 sat > 90%), full code, albuterol/ipratropium nebulizers every 4 hours as needed for shortness of breath, hypoxia, wheezing.
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