HPI:

Mr. M is a 65 year-old male with a significant PMH of extensive tobacco use, HTN, atrial fibrillation, type
2 diabetes mellitus who presented with a 4-5 week history of shortness of breath, cough and worsening
dyspnea on exertion to the ER on 1/5/2018. He had “bad cough” which caused pain radiating to the back
with a 10/10 severity. He also attests to fevers, chills and night sweats that would interrupt his sleep at
night and cause him to yell “I cannot breathe” after which an albuterol inhaler provided marginal relief.
His travel history is significant for a trip to Arkansas a few days after his onset of symptoms, states that
he was in close proximity to friends who had the flu-like symptoms, including the cold and cough,
throughout the weekend. On his return to Houston, Mr. M had worsening of shortness of breath with
nausea and productive cough that yielded rusty sputum. He admits to having a slight sore throat that
doesn’t seem to nag him. He denies any change in notable change in bowel movements, chest pain,
weakness or appetite from baseline, although he says he has gained 10 lb over the past two weeks.

Social History

Tobacco:
States that he was born on a tobacco farm and has been smoking cigarettes since he was very young,
although on repeated questioning was unable to give a specific # of packs/day. Mentions that he
stopped smoking as a New Year Resolution (2018)

Alcohol:
He states that he quit drinking as of the New Year as well, and speaks of no history relating to
problematic abuse

Illicit drugs:
Never used

Living situation:
Lives with his wife, 3 dogs, and 3 cats and has no complaints

Diet
His wife helps him watch his food intake and says he has a few “cheat days” every now and then but
keeps a tab on his glucose levels regularly

Family History:
No significant family history on his father’s sides but mother had Alzeheimer’s and Diabetes. Extended
relatives on Mother’s side had cancer

Physical
General: Seemed well-developed and in a state of well-being
HEENT: mucus membranes moist
Neck: No lymphadenopathy or carotid bruits, 2+ pulses bilaterally
Pulm: Normal respiratory effort but diminished breath sounds with mild wheezing heard on auscultation
Cardio: normal S1 and S2 but fast rate felt on palpation. No murmurs on auscultation
Extremities: No edema, clubbing, cyanosis
Skin: Rashes on right upper axilla
Neuro: Alert and Oriented to Time, Place and Person, normal strength and sensation
ASSESSMENT
My assessment is that this patient is a 65-year old male with HTN, HLD, DMT2, HFpEF, s/p Hepatitis C
cure in 9/2017 who presented to the ER on 1/6/2018 with subacute onset shortness of breath,
congestion and cough in the setting of atrial flutter with RVR and HR consistently in 130s despite
metoprolol and diltiazem trial.

PLAN

COPD (presumed) exacerbation

-maintain scheduled nebulizer treatment + steroid taper (levobuterol, ipratropium, prednisone)
-initiate antibiotic prophylaxis with azithromycin for 5-10 days if change in SOB/productive cough
-repeat CXR to evaluate for consolidation or edema
-monitor pulse oximetry

Atrial Flutter with 2:1 block

-CHADsVASc score: 3
-Continue anticoagulation with apixaban
-Metoprolol 5 mg q6h
-consider digoxin (vs amiodorane) challenge to see if HR stabilizes

Heart Failure
-recheck BNP to r/o or support dx of HF (BNP on admission = 200)
-repeat Echo to assess for LV systolic dysfxn (last 45% in March, 2017)

Diabetes Mellitus Type 2

-continue sliding scale insulin + Detemir 35 mg
-continue daily glucose monitoring