26 Jun Week 1: Cardiovascular Clinical Case Patient Setting: 52 y
Week 1: Cardiovascular Clinical Case Patient Setting: 52 year old Irish American Male that was hospitalized 2 weeks ago for a stent placement. Presenting to your clinic today for follow up as he has not felt well. He sates he has been lightheaded and felt palpitations of his heart. He has also had shortness of breath the last 2 days. HPI Walks 2 miles daily and rides an exercise bicycle 3 times a week; has previously felt the palpitations associated with exercise that usually went away with rest; 2 days ago while washing dishes he began to feel shortness of breath and felt that his heart was racing; He hoped the palpitations would go away but they have continued and that is why he is here today. PMH History of hypertension for 10 years hyperlipidemia for 5 year status post stent placement 2 weeks ago and rheumatic heart disease (mitral valve) as a child. He reports adhering to a low cholesterol low fat diet for the last 2 years. Past Surgical History Stent placement 2 weeks ago. Family/Social History Family: Noncontributary Social: Smoked 15 pack/year X 20 years. Quit 5 years ago. Medication History Lisinopril 20 mg PO QD Furosemide 20 mg PO QD Gemfibrozil 600 mg PO BID Allergies NKDA ROS Otherwise negative. Physical exam BP 160/90 (clinic visit 2 months ago 155/85) HR 146 RR 22 T 98.6 F Wt 254 Ht 5 7 Gen: Well developed male in moderate distress. HEENT: PERRLA (-) JVDm mild AV nicking. Cardio: Rate irregularly irregular no murmurs or gallops. Chest: Clear to auscultation. Abd: soft non-tender active bowel sounds. GU: Deferred. Rectal: Normal. EXT: No edema normal pulses throughout. NEURO: A&O X3. Laboratory and Diagnostic Testing Na – 136 K – 4.5 Cl – 97 BUN – 20 Cr – 1.2 Total Chol- 240 Trig 180 INR 1.1 Chest Xray – Clear ECG Atrial Fibrillation no P waves variable R-R interval normal QRS
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