DATE OF VISIT: MM/DD/YYYY
CHIEF COMPLAINT: Pulmonary hypertension with an estimated pulmonary artery systolic pressure of 50-60 on recent echocardiogram, hypertrophic nonischemic cardiomyopathy with normal systolic function, home oxygen therapy 3 liters at rest, 4 liters with activity starting today.
HISTORY OF PRESENT ILLNESS: The patient is a very pleasant (XX)-year-old woman who we saw for what we thought was chronic obstructive pulmonary disease and pulmonary hypertension, which was recently diagnosed on an echocardiogram. We walked her in the hall today, and her oxygen saturation did drop down to 86% on 3 liters of home oxygen. Therefore, we have recommended that she use oxygen 3 liters at rest and 4 liters with activity.
Her chest x-ray looks like she has some congestion on it when we checked it two months ago. We recommended that she continue her Lasix 60 mg twice daily and watch her salt intake. Her pulmonary hypertension stems from the fact that this echocardiogram from last month shows an estimated pulmonary artery systolic pressure of 50-60. This was not mentioned on a previous echocardiogram from two years ago. We are wondering if she is fluid overloaded. Her BNP is over 600. Although it was better than her previous BNP, she may have elevated left-sided pulmonary venous pressures causing her pulmonary hypertension. We discussed this with her and her family today, and they are not interested in having a right-sided heart catheterization at this time.
PAST MEDICAL HISTORY: Active cigarette smoking of one pack per day only from age 18 to age 23. Her husband did smoke for 22 years in the house. She is status post a percutaneous transluminal coronary angioplasty seven years ago, history of congestive heart failure with recent admission two years ago; sarcoidosis, now with a clear chest x-ray, we do not believe that this is causing her pulmonary hypertension; peptic ulcer disease; hypertension; type 2 diabetes; ejection fraction 65%.
CURRENT MEDICATIONS: Norvasc 5 mg daily; aspirin 81 mg daily; insulin; Colace; Combivent 2 puffs twice daily, but her family states that she is not taking this and she states that she is; Diovan 40 mg one tablet daily; Feosol 45 mg; Lasix 20 mg two to three tablets twice a day before meals; Humulin insulin; Lipitor 80 mg daily; metoprolol 100 mg twice a day; multivitamins; spironolactone 25 mg one-half tablet daily; theophylline CR 200 mg daily; Verelan PM 300 mg one capsule daily.
ALLERGIES: No reported drug allergies; however, ACE inhibitors and ARBs caused hyperkalemia and an increased creatinine.
SOCIAL HISTORY: The patient is married and lives with her husband. Her husband and her grandson were with her on her last visit, but she is here with her son today.
PHYSICAL EXAMINATION: Blood pressure 108/62, heart rate 74, oxygen 95%. Chest is clear. Cardiac exam reveals regular rate and rhythm.
ASSESSMENT AND PLAN:
1. Pulmonary hypertension: We will repeat her echocardiogram in five months, and we will see her in six months.
2. Chronic obstructive pulmonary disease: Her pulmonary function test looked more restricted than obstructed. However, she does have some concavity to the expiratory limb in the flow volume curve. Her vital capacity, however, is low at 54% of predicted. We are wondering if this is secondary to congestive heart failure or if this is real restriction. Her chest x-ray does not show congestive heart failure at this time.
3. Shortness of breath with ambulation: We recommended that she take two inhalations of Combivent 20 minutes prior to coming to the doctor. We also recommended that she increase her ambulatory oxygen to 4 liters and use 3 liters at rest.
We will see her back in six months. We will get an echocardiogram before that and discuss the results of this. When we see her back, she will get a walking oximetry test and pulmonary function test.
