Identifying Information: R.S. is a 68-year-old man admitted to the hospital on September 3, 2017.

The
history is obtained from the patient, and he is considered to be a reliable historian. Chief Concern:
“Having a hard time catching my breath.” History of Present Illness The patient is a 68-year-old man with
type 2 diabetes mellitus and hypertension who presented to the emergency department on 9/3/17 with
5 days of increasing difficulty in breathing. At that time he began to note increasing difficulty breathing
when he would go up the steps in his home. This became progressively worse over the next several days
to the point where he was feeling uncomfortable breathing even at rest. In that time he also has been
having increasing difficulty sleeping at night, having to prop himself up on 4 pillows and waking up short
of breath over the past 3 nights. He had to spend the entire night before his admission sitting up in a
chair because he couldn’t lie down without becoming short of breath. Finally, when he “couldn’t talk
without losing [his] breath,” he called 911 and was transported to the hospital. R.S. has no prior history
of these episodes and reports no prior history of cardiac or pulmonary disease. He reports no chest pain.
Before the onset of these symptoms 5 days ago, he would go for daily walks with his dog and have no
dyspnea or chest pain. He does report swelling developing in his ankles and feet over the past several
days. He has also noticed a weight gain over the past several days of about 8 pounds, despite having a
poor appetite. As far as he knows, his diabetes and hypertension have been well controlled, and he last
saw his physician 2 months ago. He has had no cough, sputum production, hemoptysis, wheezing, fever,
or chills. He does not report a history of hyperlipidemia or smoking but does report a family history (FH)
of coronary artery disease in his parent and brother. Past Medical History Childhood Illnesses: Reports
having all “usual childhood illnesses”; unable to recall specific ones.

Adult Illnesses 1. Hypertension—diagnosed in 2003, on medication since 2005 and reportedly well
controlled 2. Diabetes mellitus (type 2)—diagnosed in 2003, on oral medicine since time of diagnosis.
Last hemoglobin A1c 7.2% 2 months ago. No history of retinopathy, nephropathy, or peripheral
neuropathy. 3. Hypothyroidism—diagnosed 2007, last TSH (thyroid-stimulating hormone) was 1.05 in
2016 Prior Surgery 1. Appendectomy—1959 2. Inguinal hernia repair, left side—1967 3. Sigmoid
colectomy for sessile villous adenoma, 1999; last colonoscopy was 2014 and was without pathology
Medications on Admission Hydrochlorothiazide 25 mg by mouth each day (hypertension) Lisinopril 20
mg by mouth each day (hypertension) Metformin 1000 mg by mouth twice daily (diabetes) L-Thyroxine
100 mcg by mouth each day (hypothyroidism) Acetaminophen as needed (used rarely for knee pain)
Multivitamin (Centrum Silver) one by mouth each day No herbal medicines or other over the counter
medicines Allergies Penicillin: causes hives, no history of anaphylaxis No known environmental or food
allergies Family History The patient’s parents are deceased. His father died at age 61 of complications of
colon cancer. He also had type 2 diabetes mellitus. His mother died at age 72 of a myocardial infarction.
She also had an ischemic stroke at age 68. She was a smoker and had hypertension as well as
hypothyroidism. The patient has one living brother at age 70 who has coronary artery disease and had a
coronary artery bypass graft last year.

He also has type 2 diabetes, is a smoker, and has mild chronic obstructive lung disease (COPD). He has
one brother who died in a motor vehicle accident at age 20. He had no prior medical problems. He has
one sister who died at age 54 of breast cancer, without other medical problems. The patient has three
children (two sons aged 46 and 44 and a daughter age 41), two of whom are in good health. One of his
sons was diagnosed with hypertension at age 37. There is no other family history of heart disease,
diabetes, or cancer. He has no history of anyone in his family having a similar presentation to his current
illness.
Social History The patient was born in Louisville, KY. He completed school through the tenth grade and
then joined the military for 5 years. After his military service, he moved to Baltimore and worked at City
Marine Terminal for his entire career. He retired at age 60. He was exposed to asbestos and a variety of
chemical agents through much of his career but couldn’t specify. He is now retired and spends time with
his grandchildren and working on his house. He was married at age 20. He and his wife were together
for 44 years until her death 4 years ago due to lung cancer. He has three children, all of whom live in the
area, and five grandchildren; he reports a good relationship with them. He is still grieving his wife’s
death but feels that things are getting easier. He lives independently in the same house in which he and
his wife raised their children. He is not currently sexually active and has not been since his wife’s death.
He has no prior history of sexually transmitted infections. He has never smoked, and he drinks one to
two beers a month. He reports that he used to drink heavily during his military service but has not since
that time. He reports no recreational drug use. The patient does not get regular exercise other than
walking his dog for about 30 to 40 minutes each morning. He does not watch his diet as closely as he
thinks he should but does try to avoid sweets because of his diabetes.

Review of Systems Constitutional: weight as per history of present illness (HPI); no weakness, fatigue,
fever, or night sweats Eyes: He does wear glasses for reading only. He has no blurred vision, eye pain,
redness, tearing, diplopia, or flashing lights. Ears: no hearing loss, tinnitus, discharge Nose: no nasal
congestion, epistaxis Mouth and throat: wears upper dentures, last saw dentist 4 months ago, no mouth
dryness, throat pain, hoarseness Neck: no lumps or swollen glands, pain, or neck stiffness Respiratory: as
per HPI Cardiac: as per HPI Gastrointestinal: No dysphagia, heartburn, dyspepsia, nausea, vomiting. He
does report constipation over the last 5 to 6 years, no change recently. No blood in stool or black tarry
stool. No abdominal pain, or diarrhea. Genitourinary: Urinary frequency and nocturia over the past year,
6 times per night. No hesitancy, urgency, dysuria, or hematuria. No penile discharge or pain, no
testicular pain. He has not been able to have an erection for 3 years. Peripheral vascular: no intermittent
claudication, no leg cramps Musculoskeletal: mild bilateral knee pain with extended ambulation, stable
over the last 1 to 2 years; no other joint pain, stiffness, swelling, or muscle pain Hematologic: no easy
bruising, bleeding, or history of blood clots; no prior blood transfusions

Endocrine: as per HPI and PMH Skin: no rashes, dryness, color change, or abnormalities of hair or nails
Neurologic: no headaches, head injuries, lightheadedness, vertigo, syncope, seizures, focal weakness,
numbness, paresthesias, tremor, gait instability or falls, or declining memory Mental health: Despite
experiencing grief over his wife’s death at times, he expressed no pervasive sadness or worry, and feels
optimistic about the future. Before this current illness, he had good energy, and reports good memory,
concentration, and interest in activities. Physical Examination General appearance: This is a well-
developed white man appearing his stated age, in no respiratory distress sitting up in bed. He is alert
and cooperative with the examination. Vital signs: heart rate 68 beats per minute, blood pressure (left
arm, regular adult cuff) 135/70, temperature (oral) 37° C, respiratory rate 18 per minute, pain 0/10,
weight 65 kg HEENT: Head is normocephalic without scalp or facial tenderness. Eyes: Conjunctivae are
pink and sclerae are without injection or jaundice. Bilateral arcus senilis is present. Pupils are equal in
size and react equally (4–2 mm) to light. Fundi showed sharp disc margins, and arteriole/venous nicking
was present. No hemorrhages or exudates seen. Ears: External auditory canals had moderate cerumen
(left greater than right). Tympanic membranes were intact and without erythema. Hearing was grossly
intact. Nasopharynx mucosa was pink with slight septal deviation from left to right. The oropharynx had
no lesions or exudates, and the mucus membranes were moist. Upper dentures were present, lower
teeth were in good repair. Neck: Trachea was midline, the thyroid was not palpable. Jugular venous
distention was present (approximately 9 cm). Hepatojugular reflux was present. Carotid upstrokes were
strong without bruits. No meningismus. Lymph nodes: No cervical or axillary lymph nodes were
palpable. Small, shoddy, rubbery, mobile, nontender inguinal nodes were present bilaterally, all
approximately 5 mm in size. Chest: Thoracic expansion was symmetric. There was dullness to percussion
at both bases. Diaphragmatic excursion was difficult to assess due to dullness to percussion at the bases.
Breath sounds were remarkable for crackles up to the angle of scapula bilaterally. No rhonchi, wheezes,
or stridor. No egophony, bronchophony, or tactile fremitus. Cardiac: Point of maximal impulse is noted
in the fifth intercostal space 4 cm laterally from the midclavicular line. Regular rate and rhythm. S1
normal, S2 physiologically split. S3 is present, no S4. A II/VI blowing, holosystolic murmur was present at
the apex radiating into the axilla. Abdomen: Nondistended, no tenderness to palpation. Bowel sounds
were present but hypoactive. No masses were palpable. The liver span percussed to 8 cm and the edge
was smooth and palpable 2 cm below the right costal margin. The spleen was not palpable. GU: Penis
and testicles are without lesions. No inguinal hernias are present. Rectal examination had intact tone.
Moderately enlarged, firm, symmetric, nontender prostate without nodules. Extremities: No cyanosis or
clubbing. 1+ pitting edema was present in the lower extremities up to the knees and was symmetric.
Peripheral pulses at the dorsalis pedis and posterior tibial positions were palpable and strong bilaterally.
Musculoskeletal: Hands were without joint deformities with good finger curl and wrist movement.
Bilateral knees showed mild hypertrophic joint deformity with reduced range of motion in extension
bilaterally (to about 160 degrees). No erythema, warmth, tenderness, or effusion. Bulge sign negative.
Other joints unremarkable. Skin: Warm and dry, no rashes. Tattoo present on right shoulder. Well
healed incisions over abdomen in the left inguinal region and right lower quadrant. Hair with male-
pattern baldness. No skin or nail lesions. Neurologic 1. Mental status—Awake, alert, and attentive.
Oriented in all spheres. Speech fluent and repetition intact, able to point way out of room. Mood is
euthymic and affect is appropriate to situation with full range. Thoughts are appropriate; no evidence of
disordered thinking. 2. Cranial nerves—II–XII are intact: visual acuity 20/20 with correction, visual fields
intact, extraocular movements intact, facial sensation and movement—intact, hearing intact, soft palate
—elevates well, tongue protrudes in midline, intact shoulder shrug. 3. Motor—Intact and symmetric; no
pronator drift; strength 5/5 in deltoids, finger extensors, hip flexors, and foot dorsiflexion bilaterally 4.
Sensory—Intact to monofilament and fine touch, fingers, midthighs, toes—bilaterally. Vibratory sense
intact of great toes bilaterally. Proprioception in toes intact. 5. Reflexes—2+ and symmetric in biceps
and patella. Babinski reflex negative. 6. Coordination/gait—Intact finger to nose bilaterally. Intact rapid
alternating movement. Stands and walks 10 feet without difficulty. Romberg negative; tandem walk,
heel walk, toe walk intact. Assessment R.S. is a 68-year-old man who presents with new-onset dyspnea
on exertion, orthopnea, and paroxysmal nocturnal dyspnea of 5 days’ duration. His physical examination
is significant for the presence of jugular venous distention, hepatojugular reflux, a displaced point of
maximal impulse with an S3 and a holosystolic murmur, and peripheral edema. The most likely etiology
for his illness is congestive heart failure. Other etiologies for the progressive dyspnea include
pneumonia, pulmonary embolus, pneumothorax, pleural effusion, and pericardial effusion. However,
the history and findings are most consistent with congestive heart failure, and the absence of fever and
constitutional symptoms argues against pneumonia. His physical examination is not consistent with a
pneumothorax or pulmonary embolus. He likely does have pleural effusions present based on his
examination, but this is most likely secondary to congestive heart failure. In this patient the most likely
explanation for congestive heart failure is coronary artery disease given his multiple risk factors, with the
possibility of a silent myocardial infarction in the setting of diabetes. Other etiologies

to consider would be primary valvular disease given a murmur consistent with mitral regurgitation, but
the rapidity with which his symptoms developed argues against this being the sole answer. He could
have a primary cardiomyopathy either from long-standing hypertension, hypothyroidism, or alcohol
(although his use is limited, unless he is underreporting his current use). Much less likely would be an
occupational exposure such as to heavy metals given his work in the shipyard.

Plan 1. Cardiac: Obtain chest radiograph, complete metabolic panel and complete blood count, and an
electrocardiogram. • Perform serial cardiac enzyme screening to evaluate
for myocardial infarction. • Obtain echocardiogram to assess
chamber size, valvularand left ventricular function. • Give oxygen 2
L/min and begin diuresis with furosemide, 20 mg IV every 12 hours. •
Monitor intake/urine output, daily weight, and electrolytes. • Consider
further assessment for coronary artery disease pending results of data
above. 2. Endocrine: Hold metformin while in the hospital if contrast studies needed. Monitor finger
sticks with sliding scale insulin for glucose control. Obtain hemoglobin A1c and thyroid stimulating
hormone. 3. Ophthalmology: Continue current eye drops for glaucoma. 4. Musculoskeletal: As needed
acetaminophen for likely bilateral osteoarthritis of his knees. 5. Health maintenance: Consider
Pneumovax given diabetes. Consider influenza and zoster vaccine. Up to date with cancer screening.