CHF Writeup

Subjective
CC: Pt c/o SOB
HPI: A 73-year-old Caucasian male presents to the PCP with SOB for the past 24 hours. Pt
stated that the SOB was worse when he was walking around. He states that this has never
happened before. He says that he has a history of HTN, but has not taken his meds in months.
He states that there are no alleviating factors.
PMHx
Childhood Illnesses: None
Adult Medical hx: HTN
Hospitalizations/Surgeries: none
Allergies: NKDA
OTC Meds/Herbal supplements: none
Medications (BC): Stopped taking Lisinopril for HTN.
Immunizations: Had annual flu shot and is currently up-to-date.
Screening Tests: Has had regular prostate and colonoscopy exams.
FHx: Father died of stroke at 80. Mother died of lung cancer at 85. No siblings.
SocHx: Pt lives with wife.
Smoke: Pt does not smoke
ETOH: Drinks a couple beers occasionally on weekends.
Drugs: Never
Marital status/children: Married, no children.
Diet/nutrition: Eats anything.
Exercise: Does not exercise
Occupation/exposures: Retired.
REVIEW OF SYSTEMS:
General: Admits to fatigue for the past few days. No weight loss or dizziness.
Skin/Nails: Denies lesions or pitting of nails.
Head:Denies headache or injury.
Eyes: Denies eye pain or problems with vision.
Ears: Denies ear pain or ringing in ears.
Nose: Denies congestion, or lesions
Sinuses: Denies recurrent infections.
Mouth/throat: Denies sore throat or problems swallowing.
Neck: Denies stiffness or pain.
Pulmonary: Admits to SOB and dyspnea on exertion (see HPI).
Cardiac: Denies tightness or palpitations.
GI: Denies nausea, diarrhea, or vomiting.
GU: Female/Male: Admits to increased urinary frequency. Denies pain with urination.
Musculoskeletal: Denies stiffness or weakness in joints.
Endocrine: Denies hot or cold intolerance, or excessive thirst.
Neurologic: Denies convulsions or seizures.
Psych: Denies anxiety or depression.
Hematology: Denies history of blood transfusions or bleeding.

Peripheral vascular: Admits to swelling in legs. No history of varicose veins.

Objective
General: Pt appears tired and pale with mild, labored breathing.
Vitals: BP: 140/100 P: 85 T: 98.7 RR: 24
PulseOx: 97% Ht: 61 Wt: 189 lbs
Skin/Nails: Capillary refill <3s. Skin warm and dry; turgor normal. No suspicious lesions.
Head: normocephalic, atraumatic.
Eyes: 2:1 disc to cup ratio. Pupils equal and round. No AV nicking, papilledema, or cotton-wooly
patches.
Ears: TMs intact w/ good light reflex. No exudate.
Nose: No exudate or suspicious bumps.
Mouth/throat: Pt has no teeth and wears dentures. Lips are dry w/o lesions. Uvula midline.
CN 9/10 intact.
Neck: JVD present. No thyroidmegaly, masses or bruits.
Breast/pectoral: No masses or skin changes.
Lymphatics: No cervical lymph node enlargement.
Pulmonary: Rales noted at both bases of lungs.
Abdomen: No renal, iliac, or femoral bruits. No pulsating aortic mass.
Cardiac: Diminished S1 mitral. S3 gallop. Felt lift/ thrill when palpating chest wall.
GI: No tenderness upon palpation of bladder.
Musculoskeletal: No stiffness when moving joints.
Neurologic: Appears alert and oriented when speaking. CN 9/10 intact.
Hematology: No unusual bleeding or clotting noted.
Peripheral vascular: Pitting +2/+3 edema in legs. Pulses intact. No clubbing of fingers or
cyanosis.
LABS
CBC, CMP (lipid profile), cardiac enzymes, BNP (elevated 300), EKG (shows ST depression),
chest x-ray (shows mild atelectasis).
Assessment/ Differentials
1. CHF (possibly due to noncompliance with HTN meds)
2. Hypertension
3. Dilated cardiomyopathy
4. Pulmonary embolism
5. Possible past MI?
Plan
1) Take hydrochlorothiazide 50 mg/day for edema and HTN.
2) CHF- Take digoxin 0.25 mg daily po. Start beta blocker (metoprolol 50 mg/ day) po.
3) Hypertension- Discuss reasons for stopping Lisinopril and recommend taking at 10
mg/day po.
4) Discuss cutting down on alcohol intake.
5) Order Echo.
6) Refer to cardiologist.