Week 1: Cardiovascular Clinical Case

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