HPI: Patient complains of severe intermittent SOB worse when laying supine and
associated with lower extremity edema.
PFSH: Remarkable ischemic cardiomyopathy with EF of 20%, 20 pack year smoking
history and strong family history of premature cardiovascular disease.
ROS: Constitutional: No fevers, chills, weight loss. CV: No chest pain or palpitations.
GI: No N/V/D. All other systems reviewed and are negative.
EXAM: CONSITUTIONAL: NAD, conversant. BP 166/80, HR 82, T 98.0. EYES
have anicteric sclerae; no lid-lag or proptosis. ENMT exam is normal. CV: RRR, no
MRGs. There is bipedal edema. RESPIRATORY: Lungs have bibasilar crackles
with increased respiratory effort. GI: Abdomen is soft, NABS, no HSM. MUSCULOSKELETAL
exam is normal. PSYCHIATRIC: A&OX3, normal affect.
Labs show a BUN of 54, creatinine of 2.8, potassium 4.2, sodium 142, HGB 12.1.
First troponin 0.04. CXR was reviewed and shows pulmonary vascular congestion.
EKG was reviewed and shows no diagnostic ST changes.
Impression:
1. Acute on chronic left ventricular systolic heart failure
2. New ARF, most likely cardio-renal in origin
3. Poorly controlled HTN due to volume overload
Plan:
1. BUMEX 2 mg IV Q 6H
2. DIRUIL 500 mg IV times one
3. Hold ACE inhibitor for now
4. Chem 10 in a.m.
5. DVT prophylaxis
