IDENTIFICATION: June 10, 2019

MJ, F, African American, 87 years old, widow, 56-78 198th St, Jamaica, NY 12567, Baptist.

INFORMANT: Patient accompanied by her daughter, reliable historians.

REFERRAL SOURCE: Self

CHIEF COMPLAINT: ‘Cough and bilateral leg swelling’ for 3 days

PRESENT ILLNESS: MJ is an 86-year-old female, with a PMH significant for Hypertension, Hyperlipidemia, GERD. Anxiety, CVA (2016), Atrial Fibrillation, CHF and Transthyretin Amyloid Cardiomyopathy, presents to the office for her annual physical.  Patient endorses a 3 day history of increased cough associated with nausea, decreased PO intake and loss of appetite. Patient notes the pain is worse after eating and when lying down and attributes the cough to her ‘acid reflux.’  Reports drinking a Boost shake daily, denies vomiting, diarrhea or constipation.

Patient also reporting a 3 day history of bilateral leg swelling associated with body weakness and fatigue.  Patient notes she underwent MitraClip insertion 2 months ago and her cardiologists notes a decrease in EF following the procedure (EF: 45% → 26%). Patient denies dyspnea, chest pain, syncope or palpitations.

Of note, patient’s daughter reports patient is part of a Tafamidis clinical trial to treat the Transthyretin Amyloid Cardiomyopathy, with the goal of stunting disease progression.  Patient is followed by Cardiologist managing the TAC at NYU Langone.

PAST MEDICAL HISTORY

• Hypertension
• Hyperlipidemia
• GERD
• Anxiety
• CVA (2016)
• Atrial Fibrillation
• CHF (EF: 45% → 30%)
• Transthyretin Amyloid Cardiomyopathy

PAST SURGICAL HISTORY

• Bilateral Hip Replacement
• Pacemaker Placement (2015)
• MitraClip (2019) 

MEDICATIONS

• Xanax XR 0.5mg tablet PO qd
• Eliquis 5mg PO BID
• Furosemide 80mg PO qd in the morning
• Spironolactone 25mg PO qd in the evening
• Prilosec 20mg PO qd
• Omeprazole 40mg PO qd
• Zoloft 100mg PO qd
• Qvar Redihaler 40 mcg/act 1 puff qd
• Benzonatate 100mg PRN for cough tid
• Montelukast Sodium 10mg PO qd

ALLERGIES

• Iodine
• Levofloxacin
• Ceftriaxone Sodium
• Wheat

FAMILY HISTORY

• Mother, 90, deceased, breast cancer.
• Father, 90, deceased, DM, CHF.
• Sister, 82, alive, hyperlipidemia.
• Brother, 78, deceased, AFib, Stroke.
• Children, alive and well.

SOCIAL HISTORY

• Parents deny any EtOH, smoking or illicit drug use.  Patient is widowed, lives with her daughter and daughter’s family, does most ADLs, assisted by family where necessary.  

REVIEW OF SYSTEMS
General: Reports generalized weakness/fatigue, change in appetite. Denies recent weight loss, fevers and night sweats.
Skin, hair and nails: Patient denies excessive dryness or sweating, moles/rashes or pruritus.
Head: Patient denies intermittent headaches, vertigo, light-headedness or head trauma.
Eyes: Patient denies visual disturbances, blurring, diplopia, fatigue with use of eyes, scotoma, halos, lacrimation, photophobia or pruritus. Last eye exam unknown. Patient wears glasses.
Ears: Patient denies deafness, pain, discharge, tinnitus.  Patient does not wear hearing aids.
Nose/Sinuses:  Patient denies discharge, epistaxis, obstruction.
Mouth and throat: Patient denies dry mouth, sore tongue, mouth ulcers, bleeding gums, sore throat or voice changes.  Patient wears dentures.
Neck:  Patient denies localized swelling/lumps or stiffness/decreased range of motion.
Breast: Patient denies lumps, nipple discharge or pain.
Pulmonary System:  Patient reports cough. Patient denies dyspnea (SOB), dyspnea on exertion (DOE), hemoptysis, cyanosis, orthopnea or paroxysmal nocturnal dyspnea (PND).
Cardiovascular System: Patient reports edema/swelling of lower extremities.  Patient denies intermittent chest pain, HTN, palpitations, irregular heartbeat, syncope or known heart murmur.
Gastrointestinal System: Patient denies abdominal pain, constipation, change in bowel habits, nausea, vomiting, changes in appetite, intolerance to specific foods, dysphagia, pyrosis, flatulence, eructations (belching, burping), diarrhea, jaundice, hemorrhoids, rectal bleeding or blood in stool.
Genitourinary System: Patient denies dysuria, urgency, frequency, nocturia, oliguria, polyuria, discoloration of urine, incontinence, awakening at night to urinate or flank pain.

1. Sexual History 

• • Patient is widowed and no longer sexually active.

Nervous System: Patient denies headache, seizures, loss of consciousness, sensory disturbances, numbness, parethesias, dysesthesias, hyperesthesias, ataxia, loss of strength, change in cognition / mental status.
Musculoskeletal System: Patient denies any joint pain, arthritis, deformity or swelling, redness.
Peripheral Vascular System: Reports peripheral edema of lower extremities.  Patient denies intermittent claudication, coldness or trophic changes, varicose veins or color change.
Hematologic System:  Patient denies history of PE, anemia, easy bruising or bleeding, lymph node enlargement.  Patient denies blood transfusions.
Endocrine System:  Patient denies polyuria, polydipsia, polyphagia, heat or cold intolerance, goiter, excessive sweating.
Psychiatric: Patient denies depression/sadness, feelings of helplessness, feelings of hopelessness, lack of interest in usual activities, suicidal ideations, anxiety, obsessive / compulsive disorder.  

GENERAL SURVEY: 87-year-old female A/O x3.  Patient appears to be of stated age, pleasant and in no acute distress.

VITALS
BP: 104/74 mmHg
R: 16 BPM
P: 96 BPM
SpO2: 98% on RA
Temperature: 98.5 F
Height: 66 inches Weight: 142 lbs BMI: 22.92

PHYSICAL EXAM
SKIN:  Warm & dry, good turgor.  Nonicteric, no lesions, no tattoos.
HAIR: Small quantity and equal distribution.
NAILS: No clubbing, capillary refill <2 seconds throughout.
HEAD: NC/AT nontender to palpation throughout.
EYES: No conjunctival injection, bilaterally, cornea clear. EOMI bilaterally, no discharge, no evidence of strabismus, exophthalmos or ptsosis.
EARS: Symmetrical & normal size. No evidence of lesions, masses, trauma on external ears. No discharge or foreign bodies in external auditory canals AU.
NOSE: Symmetrical, no obvious masses, lesions, deformities, trauma, discharge. Nares patent bilaterally, nasal mucosa pink & well hydrated. No discharge noted on anterior rhinoscopy. Septum midline without lesions, deformities, injection or perforation. No evidence of foreign body.
LIPS/MOUTH: pink, moist, no evidence of cyanosis, masses or lesions, well hydrated. No evidence of leukoplakia.
TEETH: good dentition, no missing teeth or discoloration.
TONGUE: Pink, well papillated, no masses, lesions or deviations noted. Oropharynx not well hydrated, no evidence of injection, exudates, masses, lesions, foreign bodies. Tonsils present with no evidence of injection or exudates. Uvula pink, no edema, lesions.
NECK: Supple, no lymphadenopathy.
LUNGS: Clear to auscultation bilaterally. Chest expansion symmetrical. No wheezing, rhonci, crackles, rales noted.
HEART: RRR. S1 & S2 normal. (+) murmur noted, no gallops noted.  Carotid pulses 2+ bilaterally.
ABDOMEN: BS active in all four quadrants.  Soft, non-tender, not distended. No CVA tenderness.
VASCULAR: 1+ pitting edema bilaterally. The extremities are normal in color, size and temperature. Pulses are 2+ bilaterally in upper and lower extremities. No clubbing or cyanosis noted bilaterally (no C/C B/L).
NEURO: Alert and oriented to person, place and time. Memory and attention intact. No gross deficits.
MUSCULOSKELETAL: No soft tissue swelling / erythema / ecchymosis / atrophy / or deformities in bilateral upper and lower extremities. Non-tender to palpation / no crepitus noted throughout.

ASSESSMENT: 87 year old female, with PMH significant for Hypertension, Hyperlipidemia, GERD. Anxiety, CVA (2016), Atrial Fibrillation, CHF (EF: 45% → 30%) and Transthyretin Amyloid Cardiomyopathy presents for her annual physical endorsing a 3 day history cough, bilateral lower extremity edema, decreased appetite and weakness likely due to CHF exacerbation and GERD flare.

DIAGNOSTICS:

• LABS:

1. 1. EFGR: 48 (L)
   2. Glucose: 85
   3. Sodium: 126 (low)
   4. Potassium: 3.6
   5. Chloride: 85 (L)
   6. CO2: 29
   7. Urea: 21
   8. Creatinine: 1.05 (high)
   9. BUN/Creatinine: 20
   10. Calcium: 9.5 
   11. Protein: 6.3
   12. Albumin: 4.0
   13. Bilirubin: 1.9 (H)
   14. Alk Phos: 76
   15. AST: 37 (H)
   16. ALT: 31 (H)
   17. Hgb A1C: 5.8 (H)

PLAN:

• Congestive Heart Failure secondary to Transthyretin Amyloid Cardiomyopathy

1. 1. 1. Managed by Cardiology at NYU Langone
      2. Active participant of Tafamidis Phase III Clinical Trial NCT 01994889
         1. Continue taking Tafamidis 61mg PO qd as prescribed by cardiologist
      3. Continue Furosemide 80mg PO qd in the morning and Spironolactone 25mg PO qd in the evening to help manage increased leg swelling
      4. Call placed to cardiologist with follow up arranged for early next week 

• GERD without esophagitis

1. 1. 1. Start Dexilant Capsule Delayed Release, 30mg PO qd to alleviate GERD symptoms and cough 
         1. Patient encouraged to avoid salty and greasy foods 
      2. Stop Omeprazole 40mg PO qd
         1. Minimal relief provided 

• Anorexia

1. 1. 1. Start Cyproheptadine HCL 4mg PO tid with meals to help stimulate appetite
      2. Continue drinking boost daily to help maintain body habitus / stay nourished

• Hypertension

1. 1. 1. HTN medications held for clinical trial

• Hyperlipidemia

1. 1. 1. HLN medications held for clinical trial 

• Anxiety

1. 1. 1. Continue Xanaz and Zofloft as prescribed

• CVA (2016)

1. 1. 1. Continue Eliquis as prescribed

• Atrial Fibrillation

1. 1. Continue Eliquis as prescribed

Differential Diagnosis

1. Transthyretin Amyloid Cardiomyopathy
2. Congestive Heart Failure
3. GERD
4. New Medication Side Effects
5. Fluid overload