HEART: Irregularly irregular rhythm; Unable to detect S3 or murmurABDOMEN: Normal contour; active bowel sounds all four quadrants; no palpable masses.PV: Pulses are 2+ in upper extremities and 1+ in pedal pulses bilaterally. 2+ pitting edema to her knees noted bilaterally.NEUROLOGIC: Achilles reflexes are hypoactive bilaterally. Vibratory perception to the 128 Hz tuning fork placed at the MTP of her great toe is absent bilaterally; She is unable to discern monofilament placement in 3 locations on her left foot and 2 places on her right foot.GENITOURINARY: no CVA tenderness; not examinedMUSCULOSKELETAL: Heberden’s nodes at the DIP joints of all fingers. Heberden's nodes and crepitus of the bilateral knees on flexion and extension with tenderness to palpation mediallyat both knees. Kyphosis.Gait slow, but steady.PSYCH: normal affect; her Mini-Cog Score is 3. Her PHQ-9 score is 22.SKIN: Sparse hair noted on lower legs and feet bilaterally with dry skin on her ankles and feet.Diagnostic results: Labs from last year’s visit: Hgb 12.2, Hct 37%, Hgb A1C 8.2%,K+ 4.2, Na+140, Cholesterol 186, Triglycerides 188, HDL 37, LDL 98, TSH 3.7, ALT/AST wnl.Current:Urinalysis: Protein 2+, Glucose: 4+ASSESSMENT & PLAN:Primary Diagnoses:1.Congestive Heart Failure (CHF) with Left Ventricular Dysfunction (ICD 9 428.1): According to Ferri (2012), CHF is the inability of the heart to keep up with the demands on it, with failure of the heart to pump blood with normal efficiency. Signs and symptoms of left-sided heart failure, which Ms. B. J. exhibits, include: progressively worsening dyspnea on exertion, orthopnea, lower extremity edema, fatigue, lethargy and
decreased functional capacity. Patient also endorses having a “heart beat problem” which can be an arrhythmia. Arrhythmias are known to be acute precipitants of Heart Failure (Ferri, 2012).Diagnostics:Order CBC (to evaluate for Anemia which decreases the oxygen-carrying capacity for blood and causes dyspnea as well as fatigue), CMP (to evaluate for any electrolyte imbalances such as hypokalemia due to fluid overload and her use of a loop diuretic, and kidney clearance/function), LFTs, TSH & Free T4 (recommended for patients with Atrial Fibrillation or known thyroid disease (Ferri, 2012)).Order BNP (elevated BNP correlates with severity of HF disease (Ferri, 2012)).Lipid profile & Hgb A1C (routine screening for Dyslipidemia/CAD as it is one of the predominant causes of CHF (Ferri, 2012)).EKG (evaluate for signs of prior MI, cardiac hypertrophy or chamber enlargement, heart block or arrhythmias (Ferri, 2012)).CXR (evaluate for pulmonary venous congestion, pulmonary edema, pleural effusion or cardiomegaly (Ferri, 2012)).Transthoracic echocardiogram (evaluates left ventricular ejection fraction and is a useful tool in assessing systolic, diastolic and valvular structure function (Ferri, 2012)).
- Spring '20