Cardiology Case Study 2

Cardiology

TAPE 8B, Report 2

INITIAL OFFICE EVALUATION

CHIEF COMPLAINT

Shortness of breath.

HISTORY OF PRESENT ILLNESS

This elderly female was on Tonocard, Cardizem, Lasix, digoxin, Darvocet.  She had no oxygen in the home, and there was no one to oversee her medications.  She did quite well on Thursday and Friday, but yesterday began getting more short of breath.  Her legs were swollen last night.  She was short of breath and had to sit up to breathe last night.

PHYSICAL EXAMINATION

On physical examination, she says that she is quite comfortable at the present time.  Her neck veins are slightly distended.  Her carotids are easily felt.  There is no bruit.  Her lungs are clear to percussion and auscultation.  The heart is enlarged to the left.  There is an apical impulse that is heaving.  There is a grade 4 systolic murmur at the apex.  No diastolic component.  The breasts are atrophic.  No masses.  The abdomen is soft.  The liver is at the right costal margin.  No other masses are felt.  She has a good femoral pulse, but I cannot feel the pulse in her feet.  There is 2 to 3+ pitting edema in both legs, and a lot of superficial veins are present.

DIAGNOSES

1. Hypertensive cardiovascular disease with left ventricular hypertrophy, mitral insufficiency, and congestive heart failure.  2. She also has arteriosclerosis obliterans of the lower extremities.

She will be admitted to the hospital, started on oxygen, given intravenous diuretics.  We will try to get the edema out of her body, and then she will either need to go to a nursing home or go home with oxygen in the house, along with someone to care for her and make sure her medications are given regularly.

FOOTNOTE

Line 18.  The heading Physical Examination was added.

Line 28.  It is preferable not to use the hyphen for the word to if doing so would affect clarity.  Example:  2-3+ may be misinterpreted, whereas 2 to 3+ or 2+ to 3+ is clear.

Line 41.  The slang term meds was translated as medications.