An admission H&P for a patient with shortness of breath...
CC: Shortness of breath
HPI: Patient complains of intermittent exertional shortness of breath which began yesterday
and is associated with worsening lower extremity edema.
PFSH: Remarkable for hyperlipidemia, documented CAD s/p CABG in 1998. There is
also a strong family history of premature cardiovascular disease in several first degree
relatives and a history of tobacco abuse, although the patient quit smoking five years ago.
ROS: As reviewed in the HPI. No chest pain or cough. Otherwise non-informative.
CONSTITUTIONAL: NAD, conversant. BP 180/80, HR 72, RR 20. EYES: No ptosis.
Pink conjunctivae. PERRL. ENMT: Good dentition. No pharyngeal erythema, ulcers or
exudate. NECK: No masses or crepitus; trachea midline. No thyromegaly. LUNGS: Fine crackles
with normal respiratory effort. CV: Heart RRR with no MRGs; moderate peripheral edema. GI:
Abdomen is soft and non-tender with no HSM. SKIN: Warm and dry with normal turgor;
no rash, lesions or ulcers. PSYCH: A&OX3 with appropriate affect.
Data: EKG was reviewed and showed some flipped T waves in the anterolateral leads.
CXR was reviewed and shows bilateral pulmonary vascular congestion. Labs show normal
electrolytes, CBC and normal creatinine. Troponin is 0.88
Impression
1. New onset CHF
2. Hypertension associated with volume overload
3. CAD with elevated troponins
Plan
1. Will start intravenous loop diuretics and NTG
2. Consult cardiology
3. Echo
4. Serial troponins
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