HISTORY
Patient is an 84-year-old male who states for the last 10 days he has had a history of upper respiratory symptoms, low-grade temp, cough, just has gotten progressively worse. He states his shortness of breath has been there the whole time, but has gotten progressively worse as well. He denies any chest pain, just breathing problems. He was taking Tylenol. The night he came in, he says it just got too bad and told his wife he needed to come to the emergency room. He has coughed up some phlegm, but not a lot. Before he became ill, he was going to the Y and doing pool exercises on a p.r.n. basis. In the ER, he was noted to be in respiratory distress. He was given O2 nebulizer treatments and they got his sats up. ER doctor said he is very tight. He was responding nicely to the nebulizers and he was transmitted to the floor. He became worse during the early morning hours. ER doctor called me. His troponin was 0.9 when we got the lab back, and we transferred him to the ICU and repeated cardiac enzymes and he was given dose of Lovenox. He denies having chest pain, particularly just says it is kind of tight to breathe. He is on high-flow O2 to keep his sats up. He has crackles and wheezes; left side is now worse than the right. He was given Lasix in the ER and also given Lasix in the ICU. He has diuresed somewhat and is more comfortable now.
Patient is an 84-year-old male who states for the last 10 days he has had a history of upper respiratory symptoms, low-grade temp, cough, just has gotten progressively worse. He states his shortness of breath has been there the whole time, but has gotten progressively worse as well. He denies any chest pain, just breathing problems. He was taking Tylenol. The night he came in, he says it just got too bad and told his wife he needed to come to the emergency room. He has coughed up some phlegm, but not a lot. Before he became ill, he was going to the Y and doing pool exercises on a p.r.n. basis. In the ER, he was noted to be in respiratory distress. He was given O2 nebulizer treatments and they got his sats up. ER doctor said he is very tight. He was responding nicely to the nebulizers and he was transmitted to the floor. He became worse during the early morning hours. ER doctor called me. His troponin was 0.9 when we got the lab back, and we transferred him to the ICU and repeated cardiac enzymes and he was given dose of Lovenox. He denies having chest pain, particularly just says it is kind of tight to breathe. He is on high-flow O2 to keep his sats up. He has crackles and wheezes; left side is now worse than the right. He was given Lasix in the ER and also given Lasix in the ICU. He has diuresed somewhat and is more comfortable now.
ALLERGIES
He is allergic to SULFA.
CURRENT MEDICATIONS
1. Cardura 8
milligrams a day.
2. Norvasc 5
milligrams a day.
3. He takes
an aspirin a day.
4. Aciphex
20 milligrams a day.
5. He takes
fish oil daily.
6. Multivitamin.
PAST MEDICAL AND SURGICAL HISTORY
He had a total knee replacement in 1991 on the right. He has spinal stenosis, which is moderate to
severe, and that is why he is doing pool exercises. He has had hypertension for years. He had a TURP years ago, he cannot remember
exactly when, but he still has BPH problems.
FAMILY HISTORY
At this time is noncontributory.
SOCIAL HISTORY
He has a 90 to 100-pack-year history of smoking, but he quit
in 1982. He is married. He occasionally drinks, but not very
often.
OBJECTIVE
GENERAL: When I see
the patient, he is in ICU setting. He is
sitting at about 45 degrees, said his mouth is dry, but otherwise he is feeling
okay, just got some congestion in his chest.
ENT EXAM: His pupils
are small but reactive. Oropharynx is
dry. Lips are dry.
CHEST: He has
bilateral breath sounds with crackles on the left and the right with some
wheezing noted, but very mild. He said
it was worse before he got his treatment.
CARDIAC EXAM:
Revealed a regularly irregular rhythm with a rate of 110.
ABDOMEN: Obese. He has positive bowel sounds. He is nondistended, nontender.
EXTREMITIES: Legs, he
has bilateral trace edema, but this is kind of chronic in this gentleman. Most of it is nonpitting. There might be a little bit more on the right
than left compared to normal.
LABORATORY DATA
Include a brain natriuretic peptide of 499. His CMP showed elevated sugar of 181, this is
nonfasting; fasting is 3.7. His white
count was 13,700 with a left shift. H
and H 12.6 and 38.6 respectively. His
initial troponin was 0.96. CPK was
506. Repeat troponin came back at 2.19
with CPK of 473. Chest x-ray showed
bilateral infiltrates. This needs to be
reviewed. EKG shows atrial fibrillation
with decreased forces in the anterior chest leads.
ASSESSMENT
1. Respiratory
distress, most likely pneumonia, now complicated by congestive heart
failure. This could be aggravated by a
subendocardial myocardial infarction or new-onset myocardial infarction.
2. New-onset
atrial fibrillation with increased troponin.
3. Hypertension.
4. Benign
prostatic hypertrophy.
5. Spinal
stenosis.
PLAN
At this time, he is going to stay in the ICU. We will consult cardiology along with
critical care. He was given Lovenox and
this will be continued with his new-onset atrial fibrillation. He is on Levaquin, increased to 750 IV
daily. He is on nebulizer treatments
O2. He has been given some dig to try to
slow his rate down. With his amount of
bronchospasm, would stay away from beta blockers. Will discuss with cardiology.
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