DATE OF ADMISSION: MM/DD/YYYY
CHIEF COMPLAINT: Low heart rate and generalized weakness.
HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old female with history of COPD, active tobacco use, diabetes mellitus, hypertension, and hypothyroidism who was seen at her primary care physician’s office for routine checkup. She was noted to be bradycardic there. An EKG was obtained, which showed AV junctional bradycardia with a heart rate in the mid 30s.
The patient states that over the last few weeks, she has been feeling generalized weakness, lightheaded and dizzy, as well as palpitations. She has had intermittent chest pain for the last few weeks. The last episode of chest pain was about a week ago. It was substernal, not really associated with exertion; although, she has had dyspnea on exertion as well over the last few weeks.
Currently, she denies any chest pain. She denies any shortness of breath. She denies any recent orthopnea or paroxysmal nocturnal dyspnea. She denies any cough. She denies any fevers or chills. She denies any dysuria; although, recently, she has been treated with Keflex for a urinary tract infection.
PAST MEDICAL HISTORY: Chronic obstructive pulmonary disease, active smoker, diabetes mellitus, hypertension, morbid obesity, status post hysterectomy, and chronic kidney disease stage III.
ALLERGIES: Multiple medication allergies, listed in the chart.
MEDICATIONS: ProAir inhaler p.r.n., aspirin 81 mg daily, Lipitor 10 mg daily, buspirone 7.5 mg b.i.d., Coreg 6.25 mg b.i.d., Keflex 500 mg p.o. q.i.d., Lasix 40 mg daily, gemfibrozil 600 mg p.o. b.i.d., NovoLog sliding scale, Lantus 30 units subcu b.i.d., levothyroxine 50 mcg daily, loratadine 10 mg daily, losartan 100 mg daily, Singulair 10 mg at bedtime, fish oil 1000 mg b.i.d., Protonix 40 mg daily, potassium chloride 8 mEq daily, Lyrica 50 mg b.i.d. and 75 mg at bedtime, and trazodone 50 mg daily.
SOCIAL HISTORY: She currently smokes about a pack per day. She denies any alcohol use. She denies any illicit drug use.
FAMILY HISTORY: Positive for cardiomyopathy in her father as well as coronary artery disease in her siblings, as well as diabetes, hypertension, and obesity.
REVIEW OF SYSTEMS: A 10-point review of systems was obtained and was otherwise negative, except as stated in the history of present illness.
PHYSICAL EXAMINATION:
VITAL SIGNS: Blood pressure 172/90, heart rate 48 and regular, temperature 36.4, respiratory rate 18, and O2 sat 98% on room air.
GENERAL: The patient is alert and oriented x3. She is obese. She is in no apparent distress.
HEENT: Head is normocephalic and atraumatic. Oropharynx is clear. Mucous membranes are moist. Pupils are equal, round, and reactive to light and accommodation.
NECK: Supple. No palpable lymphadenopathy.
HEART: Bradycardic, regular. No obvious murmurs.
LUNGS: Clear to auscultation bilaterally.
ABDOMEN: Obese, soft, nontender, nondistended. Normal bowel sounds.
SPINE: No spinal tenderness.
EXTREMITIES: No cyanosis, no clubbing. She has trace ankle edema bilaterally.
NEUROLOGIC: No gross focal neurologic deficits.
SKIN: No rashes.
PSYCHIATRIC: Normal thought content and behavior.
LABORATORY DATA: Labs showed a white blood cell count of 11.4, hemoglobin 13.2, hematocrit 41, and platelets 268. Cardiac markers were negative x1. BNP was 846. Chemistry panel showed sodium of 136, potassium 4.8, chloride 104, bicarb 18, BUN 48, creatinine 2.0. Last creatinine was 1.7 last year. GFR is 24. LFTs are normal. Her coags are normal. Her TSH is 1.06.
DIAGNOSTIC DATA: A chest x-ray showed no acute cardiopulmonary abnormalities. A 12-lead EKG done in her primary care physician’s office showed AV junctional bradycardia with a rate in the 30s. Repeat EKG done in the emergency department showed sinus bradycardia with a heart rate about 50. We personally reviewed and interpreted all labs, imaging, and the EKGs.
The medical decision making was of moderate complexity in this patient who is deemed to be at moderate risk for morbidity and mortality.
ASSESSMENT AND PLAN:
The patient is a (XX)-year-old female with history of chronic obstructive pulmonary disease, active tobacco use, diabetes, hypertension, chronic kidney disease stage III, who presents with dyspnea on exertion and symptomatic bradycardia.
1. Symptomatic bradycardia. We will hold her beta blocker at this time. We will monitor on telemetry. We will give her atropine as needed and transcutaneous pacing as needed and will also check troponins and an echocardiogram and consult Cardiology in the morning for further evaluation and consideration of pacemaker placement.
2. Dyspnea on exertion and intermittent chest pain the last few weeks. Etiology is unclear. Does not appear to have a COPD exacerbation. She is not anemic. Bradycardia may potentially be causing, not sure; therefore, we will order an echocardiogram and trend troponins. The patient is a high risk for coronary artery disease and will likely need a stress test either as an outpatient or inpatient to rule out coronary artery disease.
3. Chronic kidney disease stage III to IV. Currently, her creatinine is close to her baseline. We will the dose her medications and avoid nephrotoxins.
4. Recent urinary tract infection. We will continue Keflex and repeat a urinalysis and Keflex can likely be discontinued if urinalysis is negative.
5. Diabetes. We will continue the patient on sliding scale insulin.
6. Hypothyroidism. We will continue levothyroxine.
7. Hypertension. We will continue her home antihypertensive medications except for Coreg.
8. Hyperlipidemia. We will continue her statin.
9. Deep venous thrombosis prophylaxis. Heparin subcu.
CODE STATUS: Full code.
