CASE STUDY: Resp & Cards
Chief Complaint
A 53 y/o male presents to the clinic with gradually increasing fatigue and edema in spite of increasing diuretic therapy.
Past Medical History
- Anterior MI, 2010; no surgical intervention-medical management only
- Heart failure, Stage II NY Classification
Current Medications
- Lasix 80 mg TID
- Captopril 50 mg TID
- Aspirin 160 mg daily
- Isosorbide mononitrate SR 60 mg daily
- Norvasc 10 mg daily
Review of Systems
- General: States his weight is up due to increased edema. Appetite good.
- HEENT: Denies visual changes; recent eye exam showed no change in prescription.
Denies sore throats, frequent colds, hearing difficulties.
- CV: BP in good control on current meds. Denies noticing palpitations or chestdiscomfort.
- Respiratory: Has SOB with minimal exertion, no changes noticed. Denies cough, use of/need for inhalers.
- GI: Denies abdominal pain, nausea, vomiting, diarrhea, constipation. Appetite good.
- MS: Denies swelling, redness, decreased ROM, other joint pain. Doesn't exercise often due to exercise intolerance.
- GU: Denies dysuria, urgency, frequency, nocturia.
- Neuro: Denies HAs, dizziness, confusion, syncope.
- Endocrine: Denies polyphagia, polyuria, polydipsia. Denies hair thinning, cold intolerance, weight gain, bradycardia.
- Psychiatric: Denies history of depression in family or self, although feels "down" sometimes due to heart disease.
- Physical Examination
- Vital signs: T 98.2, BP 95/48, HR 105 bpm and regular, Pulse Ox 95% on RA, HT 70, WT 165 lbs.
- General: Alert and cooperative, in no distress at rest.
- HEENT: PERRLA, EOMs parallel, full peripheral vision. Retina clear, disk margins sharp. Balding. Facial expressions symmetrical. Posterior pharynx without lesions, inflammation. No cervical lymphadenopathy. Thyroid not enlarged or nodular. Weber shows no lateralization and Rinne AC greater than BC. Able to hear whispered word at 2 feet.
- CV: NSR with S1 and S2 as single sounds, no S3 or S4. Grade II Systolic murmur heard at the left fifth intercostal space and the apex without radiation. No JVD. No carotid bruits. +3 dependent edema to bilateral lower extremities.
- Respiratory: Bibasilar crackles. Nonproductive cough. AP/lateral ratio 1:2. Costal angle less
- Abdomen: Soft, no tenderness, masses, bruits. Tympanic to percussion. No organomegaly. No shifting dullness.
- MS: Good muscle tone, strength equal, 5/5 in all four extremities. Full ROM in all four extremities and spine. Slight crepitus in left shoulder, but no restriction to movement.
- Neuro: A&O x 4. CNs II to XII intact. DTRs 2+ bilaterally, negative Romberg
Questions
1. What 5 conditions would be considered in the differential diagnosis of this patient? Please list the most likely condition first and include rationales for all.
2. What diagnostic testing would you want to order?