DISCHARGE DIAGNOSES
1. Systolic congestive heart failure, acute upon chronic, ejection fraction 30%.
2. Moderate bilateral pleural effusion.
3. Bibasilar atelectasis versus bibasilar infiltrates per CT scan of the chest.
4. Lymphadenopathy.
5. Fatigue and malaise.
6. Mitral valve regurgitation, moderate.
7. Remote history of a hemorrhagic stroke without significant residual neurological deficits.
8. Acquired and equal length of the leg.
9. Status post total hip arthroplasty in the past.
CONSULTATIONS
Dr. XXXX , cardiology. Dr. XXXXXX , pulmonary.
PRINCIPLE PROCEDURES
1. Echocardiogram.
2. Venous Doppler ultrasound of lower extremities.
3. CT scan of the chest/CT pulmonary angiogram.
REASON FOR ADMISSION
Mr. Crosby is a 79-year-old black male who presented to the office with progressive shortness of breath, onset 2-3 weeks ago, occasional cough with minimal sputum production, hoarseness for the previous 3-4 months. On the date prior to presentation the patient slept sitting up on the chair all night because of shortness of breath seemed worse when he lied down. He had also noted some blood in the sputum for several days but not recently. Admitted for further evaluation and management with appropriate consultations.
HOSPITAL COURSE
Following admission baseline lab work included a CBC, CMP, TSH, D-dimer, BNP, ABGs, EKG and chest x-ray as well as CT scan of the chest per PTE protocol. Metabolic panel was within normal limits. BNP was elevated to 1040. D-dimer elevated to 791. Cardiac enzymes as well as TSH well within normal limits. CBC was normal as well as urinalysis. Drug screen was positive for cannabinoids. ABGs showed a pH of 7.45, PCO 222.0, pO2 90, bicarbonate 15.0, and oxygen saturation 98%. Chest x-ray showed a bilateral basilar pleural effusions. Venous Doppler ultrasound of lower extremities was remarkable for the deep vein thrombosis. CT scan of the chest per PTE protocol showed no evidence of pulmonary embolus, there was mediastinal and hilar adenopathy. In addition to a small bilateral pleural effusions and bilateral infiltrates and/or atelectasis. With these findings, pneumonia was suspected and the patient was initiated on antibiotics empirically. Consultation was obtained with pulmonary and the patient was seen by Dr. XXXX, and with the diagnosis of pneumoniae was not and obtained in favour of systolic congestive heart failure, acute upon chronic. Consultation was obtained cardiology, Dr. XXXX and associates. Medical management was recommended, to include diuretics, in addition to Coreg, angiotensin receptor blockers in addition to Aldactone. Cardiac ischemic workup recommended for later on outpatient basis. Supplemental nasal oxygen provided as needed. Continued on IV Levaquin and p.o. Zithromax until pneumonia completely ruled out. With management of congestive heart failure patient's symptoms of dyspnea/shortness of breath and cough progressively improved to complete resolution. Start generate with above management the patient progressively improved to baseline status. Echocardiogram report as recorded, with an ejection fraction of 30%, and findings consistent with systolic congestive heart failure, mild to moderate mitral regurgitation. Also noted to have mild hypokalemia which was corrected. By discharge date, patient was totally asymptomatic and by this time it was agreed that patient could be safely discharged home and continued on outpatient care and followup.
DISCHARGE MEDICATIONS
1. Cozaar 100 milligrams p.o. daily.
2. Coreg 6.25 milligrams p.o. b.i.d.
3. Lasix 40 milligrams, half a tablet p.o. q.a.m.
4. Spironolactone 25 milligrams p.o. q.a.m.
FOLLOW UP APPOINTMENTS
1. Follow up appointment with Dr. XXXXXXX in 3-4 weeks after discharge.
2. Follow up appointment with me in 4 weeks, sooner should there be any problems.
DIET
Low-salt, low-cholesterol, low-fat diet.
ACTIVITY
Gradually increase as tolerated. Regular walking exercises recommended. He is safety measures and health maintenance discussed. No smoking.
CONDITION AT DISCHARGE
Improved, stable and satisfactory.
1. Systolic congestive heart failure, acute upon chronic, ejection fraction 30%.
2. Moderate bilateral pleural effusion.
3. Bibasilar atelectasis versus bibasilar infiltrates per CT scan of the chest.
4. Lymphadenopathy.
5. Fatigue and malaise.
6. Mitral valve regurgitation, moderate.
7. Remote history of a hemorrhagic stroke without significant residual neurological deficits.
8. Acquired and equal length of the leg.
9. Status post total hip arthroplasty in the past.
CONSULTATIONS
Dr. XXXX , cardiology. Dr. XXXXXX , pulmonary.
PRINCIPLE PROCEDURES
1. Echocardiogram.
2. Venous Doppler ultrasound of lower extremities.
3. CT scan of the chest/CT pulmonary angiogram.
REASON FOR ADMISSION
Mr. Crosby is a 79-year-old black male who presented to the office with progressive shortness of breath, onset 2-3 weeks ago, occasional cough with minimal sputum production, hoarseness for the previous 3-4 months. On the date prior to presentation the patient slept sitting up on the chair all night because of shortness of breath seemed worse when he lied down. He had also noted some blood in the sputum for several days but not recently. Admitted for further evaluation and management with appropriate consultations.
HOSPITAL COURSE
Following admission baseline lab work included a CBC, CMP, TSH, D-dimer, BNP, ABGs, EKG and chest x-ray as well as CT scan of the chest per PTE protocol. Metabolic panel was within normal limits. BNP was elevated to 1040. D-dimer elevated to 791. Cardiac enzymes as well as TSH well within normal limits. CBC was normal as well as urinalysis. Drug screen was positive for cannabinoids. ABGs showed a pH of 7.45, PCO 222.0, pO2 90, bicarbonate 15.0, and oxygen saturation 98%. Chest x-ray showed a bilateral basilar pleural effusions. Venous Doppler ultrasound of lower extremities was remarkable for the deep vein thrombosis. CT scan of the chest per PTE protocol showed no evidence of pulmonary embolus, there was mediastinal and hilar adenopathy. In addition to a small bilateral pleural effusions and bilateral infiltrates and/or atelectasis. With these findings, pneumonia was suspected and the patient was initiated on antibiotics empirically. Consultation was obtained with pulmonary and the patient was seen by Dr. XXXX, and with the diagnosis of pneumoniae was not and obtained in favour of systolic congestive heart failure, acute upon chronic. Consultation was obtained cardiology, Dr. XXXX and associates. Medical management was recommended, to include diuretics, in addition to Coreg, angiotensin receptor blockers in addition to Aldactone. Cardiac ischemic workup recommended for later on outpatient basis. Supplemental nasal oxygen provided as needed. Continued on IV Levaquin and p.o. Zithromax until pneumonia completely ruled out. With management of congestive heart failure patient's symptoms of dyspnea/shortness of breath and cough progressively improved to complete resolution. Start generate with above management the patient progressively improved to baseline status. Echocardiogram report as recorded, with an ejection fraction of 30%, and findings consistent with systolic congestive heart failure, mild to moderate mitral regurgitation. Also noted to have mild hypokalemia which was corrected. By discharge date, patient was totally asymptomatic and by this time it was agreed that patient could be safely discharged home and continued on outpatient care and followup.
DISCHARGE MEDICATIONS
1. Cozaar 100 milligrams p.o. daily.
2. Coreg 6.25 milligrams p.o. b.i.d.
3. Lasix 40 milligrams, half a tablet p.o. q.a.m.
4. Spironolactone 25 milligrams p.o. q.a.m.
FOLLOW UP APPOINTMENTS
1. Follow up appointment with Dr. XXXXXXX in 3-4 weeks after discharge.
2. Follow up appointment with me in 4 weeks, sooner should there be any problems.
DIET
Low-salt, low-cholesterol, low-fat diet.
ACTIVITY
Gradually increase as tolerated. Regular walking exercises recommended. He is safety measures and health maintenance discussed. No smoking.
CONDITION AT DISCHARGE
Improved, stable and satisfactory.
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