NSU Patient Case Log Case Study

INSTRUCTIONS:

Using the format below use the patient information presented at the end and make up any information that is missing. I will attach an example file. COMPLETE 9 patient logs. With the format below. I will add the 9 patient information.

FORMAT-

S Subjective: start with cc, why they are here, when did it start, how long it lasted, what did they do to intervene, ……keep it narrow but include cc, and what other subjective findings, do not go into too much details…..
PMH (in short as Dx), list all of them
O Objectives: Include ROS (either include minimum 12 systems – very short not detailed, or state “All 12 systems reviewed and negative except HPI” V.S, Lab findings (only abnormal values not all lab results, Imaging – interpretation only)
A Assessment Physical Exam (the most important one, short to the point, but address from head to toe), not the way templates have it, if you use them remove things you DID NOT assess, and bold the abnormal findings during your assessment, ex: neuro, auscultation, palpation, any asymmetry, any opened wound …..just OBJECTIVE data entry here).

P Plan: start off with cc: what is found short based on lab, imaging, or assessments, than continue what was ordered, consulted, or what was continued and recommended
ex: Acute Abdominal pain – 8/10 pain scale, LLQ, CT A/P reviled diverticulitis
Initiated IVF NS @125ml/hr, Abx empirically Zosyn
pain management with PRN Morphine 0.5 mg IV Q6 hr for severe pain,
follow blood and urine cultures
elevated WBC 17000, will continue to follow trends with am labs (CBC, CMP).
Follow temperature curve, GI consulted pending evaluation, will appreciate recomendations.

Leukocytosis – WBC 17K, monitor trends, monitor Temperature curve, continue current treatment as above

AKI – …..

HTN – chronic by history, currently stable give BP values, continue to monitor, maintain MAP >65, continue Lisinopril 20 mg/Day PO

DM – ….

GI prophylaxis – ….

VTE prophylaxis – ….

CODE STATUS – FULL CODE

Please create a template such as this one and utilize for each entry and modify per patient specific presentation and Dx to cut time and be more organized, and productive but you are still thorough and perform proper and complete documentation to professionally fulfill your obligations and establish good rapport with your team and facility you work with.

INFORMATION PATIENT: ADD ANY ADDITIONAL INFORMATION TO THE FORMAT ABOVE JUST MADE UP.

PATIENT #1:

Chief Complaint:

Patient c/o SOB.

Reason for Consultation: CHF

History of Present Illness:

This is a 57-year-old male patient follows with Dr. B in the outpatient setting. The patient has a history of mitral valve repair, aortic valve repair, hypertension, sleep apnea, congestive heart failure due to valvular disease. Patient presents to the hospital with complaint of shortness of breath. Found to have pulmonary edema on chest x-ray. Seen and examined at bedside, patient resting comfortably on room air. Denies chest pain, shortness breath, palpitations at this time. States feeling better since arrival. Reports abdominal fullness.

Laboratory results reviewed. CBC unremarkable. Reveal largely unremarkable BMP, significant for: Troponins 105, 199, 177. ProBNP 1206.

EKG reveals sinus rhythm with occasional PVCs. 82 bpm.

Assessment/Plan:

Acute heart failure

CHF exacerbation

Elevated troponin

H/O mitral valve replacement

Hypertension Controlled

Pulmonary edema, acute

– Continue diuresis to euvolemia. Agree with furosemide 40 mg IV push p.o. twice daily.

– Having many PVCs, could have precipitated CHF. Trial metoprolol tartrate 12.5 mg p.o BID.

– Monitor renal function closely.

– Monitor electrolytes and replace to keep K+ > 4.0 and Mg > 2.0.

– Strict I&Os. Daily weights.

– Will consider inpatient vs outpatient stress test vs CTA for troponins although likely demand based on trend. No chest pain.

-Patient follow up for heart failure education. Hx of MVR, HTN AVR. Patient reports feeling well today. Patient’s weight today- 228 lbs. Patient states he is trying to follow a low sodium diet but it is difficult at work. Medications reviewed and patient is taking all his medications as prescribed. Patient had a follow up appointment with Dr. B on 1/10/24 and Bumex was added. Patient denies any edema, chest pain or shortness of breath. Reinforced importance of low sodium diet, fluid restriction and daily weights. Advised to call the clinic if any worsening signs of HF. Patient to follow up in HCF in 1 week as a tele-visit.

PATIENT #2:

Patient educated on initial heart failure education and spoke with daughter who is very involved with his care. Patient is currently living in Key West. Hx. of Atrial Fibrillation, BPH, PAD, CAD. Patient recently had surgery for MVR on 1/4/24. Patient is recovering well since his hospitalization. Patient is monitoring his BP, 02 sat and weight daily. Patient is also following a low sodium diet. Medications reviewed and patient is taking all his medications including diuretic- Lasix.

Subjective:

Patient seen and examined this morning without chest pain continues with a right-sided pleural chest tube no shortness of breath. Using his incentive spirometer.

Assessment/Plan:

80-year-old gentleman with history of hypertension, peripheral artery disease, atrial fibrillation who is status post mitral valve replacement. From cardiovascular point patient has been having issues with bradycardia and tachyarrhythmias he is on aspirin and statin. Chest x -ray reviewed this morning does not show any evidence of pneumothorax. Case discussed with the cardiothoracic surgical team. Diet is advanced, GI prophylaxis famotidine. He is having bowel movements. As above patient plan to start low molecular weight heparin for DVT

prophylaxis. Continue close hemodynamic monitoring high likelihood of decompensate from cardiovascular point requiring vasoactive agents.

Acute respiratory failure

Afib

Chronic diastolic (congestive) heart failure

Gross hematuria

Hypertension

Mitral valve regurgitation

PAD (peripheral artery disease)

S/P mitral valve repair

S/P mitral valve replacement

Urethral meatal stenosis

Patient has a follow up appointment with Cardiologist- Dr. L. this week. Reinforced importance of low sodium diet, fluid restriction and daily weights. Advised to call the clinic if any worsening signs of HF. Patient will follow up in HFC in 1 week as a tele-visit.

Patient #3:

Chief Complaint:

Mr. D is a 76-year-old male with a past medical history of permanent atrial fibrillation, abnormal EKG, hypercholesterolemia, and an elevated coronary artery calcium score who presents today for a follow-up evaluation.

Assessment/Plan:

1. Permanent atrial fibrillation

Echo Doppler showed in 2022 an LV ejection fraction of 61 percent on Philips 3D heart bottle. LV function is normal upon my review. The patient has preserved EF of approximately 50 to 55 percent. Continue rate control of atrial fibrillation with metoprolol tartrate 25 mg per oral 2 times a day and anticoagulation at Coumadin clinic in hospital with warfarin. The patient goes to Coumadin clinic for goal INR 2.0-3.0

2. Hypercholesterolemia

The patient is reconsidering starting statin therapy this year after he checks his routine blood work with his PCP in the fall. The patient had an LDL level in the past in the 120s. Would recommend an LDL goal less than 100 mg/dL.

3. Elevated coronary artery calcium score

Cardiac CT calcium score equals 275 points.

Echo Doppler in 2022 showed normal LV function. Normal exercise treadmill stress test in 2022.

4. White coat syndrome without hypertension

The patient has white-coat syndrome without hypertension. The patient has had a history of normal blood pressure readings in the past with marked elevated blood pressure readings at his doctor’s office.

History of Present Illness:

This patient is a 76-year-old male who presents today for a follow-up visit.

He denies having any issues with his heart.

He underwent an echocardiogram and stress test in 2022 which were normal. His blood pressure at the time of his stress test was 140/80 mmHg.

He takes metoprolol tartrate 25 mg 2 times a day.

He takes warfarin 5 mg daily.

He inquired regarding starting the statin therapy.

Plan:

The patient will continue on the same dose of metoprolol for his rate control for A. fib. Continue low sodium, diet and exercise. Follow up with Cardiovascular Disease in 6 months.

Patient #4

Chief Complaint:

Follow-up atrial fibrillation.

Assessment/Plan

1. PAF (paroxysmal atrial fibrillation)

For now she continues warfarin as her main preference. Recommended Eliquis 5 mg twice daily however financially this is the better option for her.

Monitor clinically.

2. H/O mitral valve replacement- Bio-prosthetic mitral valve replacement in the setting of severe mitral regurgitation.

Clinically doing well

Last echocardiogram was performed in 2018 due for repeat and will order today.

3. Chronic anticoagulation

For now she continues warfarin as her main preference. Recommended Eliquis 5 mg twice daily however financially this is the better option for her.

4. Essential hypertension- Blood pressure very well controlled, continue metoprolol 50 mg daily.

6. Morbid obesity- Stays active around the house

Counseling provided regarding importance of daily activity.

As much as tolerated 30 minutes of moderate intensity exercise low-cholesterol low carbohydrate diet. Patient will follow-up in 6 months with labs and echo.

History of Present Illness:

77-year-old female with a history of: Bioprosthetic mitral valve replaced 2017, Persistent atrial fibrillation

History of permanent pacemaker Chronic anticoagulation-warfarin

Reviewed her latest pacemaker interrogation from 4/25/2023

Blood pressure well controlled per blood pressure log reviewed today

Reports no bleeding concerns on chronic anticoagulation

No other concerning cardiovascular symptoms

The patient denies having chest pain, chest pressure/tightness or chest discomfort. Denies having palpitations, syncope or presyncope, dizziness or lightheadedness. Denies LE edema, PND, orthopnea. Does not have nocturnal cough or early satiety.

-Patient will continue on warfarin as main reference, recommend Eliquis 5 mg twice daily however financially this is the better option for her. Monitor clinically and follow up in 6 months with echo results.

Patient #5

Chief complaint: Coumadin level follow up.

History of present illness:

History of mechanical aortic valve (2008), Afib Goal INR: 2.0-3.0

Home warfarin dose: 5 mg daily

Drug interactions:

Fosphenytoin (may decrease effects of warfarin) Digoxin

Concomitant antithrombotic medications: Lovenox 90 mg q 12 hrs- d/c 01/02/24

Assessment/Plan:

1/16/24: INR today is 2.9; no new Hgb/plts. Recommended resuming warfarin 2 mg today. Plan discussed with MD. RPh to f/u with INR tomorrow.

1/15/24: INR today remains supratherapeutic at 3.5; continue to hold warfarin. RPh to f/u with INR tomorrow.

1/14/24: INR today is supratherapeutic at 3.8; Hgb/plts remain stable. Given increase in INR, recommended holding warfarin today. RPh to f/u with INR tomorrow.

1/13/24: INR today is therapeutic at 2.8; Hgb/plts remain stable. Given increase in INR, warfarin dose decreased to 3 mg. Plan discussed with MD. RPh to f/u with INR tomorrow.

1/12/24: INR today is therapeutic at 2.2; Hgb/plts remain stable. Lovenox has been d/c. Recommended continuing warfarin 5 mg today. Plan discussed with MD. RPh to f/u with INR tomorrow.

1/11/24: INR = 1.8. No signs/symptoms of bleeding. Recommend to administer warfarin 5 mg today.

80-year-old male with history of mechanical aortic valve replacement in 2008 on warfarin for long-term anticoagulation therapy, hypertension, dyslipidemia, spontaneous SDH in 2018 with seizure activity. Warfarin held by neurosurgery on admission. Patient was cleared by both cardiology, neurology, and neurosurgery to resume anticoagulation with warfarin. Recommend warfarin 5 mg as per home dose. Follow up and adjustment in medication for INR level therapeutic.

Patient #6

Chief Complaint: Initial heart failure education on patient.

Pt reports feeling well. Also reports he is already being seen at MCVI as well as a cardiologist.

Assessment/Plan:

1. HFrEF (heart failure with reduced ejection fraction)

-EF 25 to 30%

-Currently well compensated and about euvolemic on exam. Weight today 99.5 kg, previously 104.1 EKG on 1/8/2020:

-Will decrease Bumex to 2 mg daily. Asked patient to continue to take daily weights and notify office if has >3lbs weight gain in 1 day or 1lb weight gain for 3-5 consecutive days.

-Continue carvedilol 12.5 mg twice daily

-Continue dapagliflozin 10 mg daily

-Continue hydralazine 50 mg twice daily

-Continue isosorbide mononitrate 60 mg daily

If renal function stable or improved will start Entresto 24/26mg BID next visit. Repeat TTE in 3 months, if EF still below 35% will refer to EP for ICD.

2. Non-ischemic cardiomyopathy

3. CAD in native artery

– Nonobstructive CAD

-Coronary CTA 2016 with mild less than 40% proximal LAD stenosis, otherwise no evidence of plaque or stenosis in LM, LCx or RCA

-Chest pain-free

-Continue aspirin 81 mg daily -Continue atorvastatin 40mg QD

4. Hypertension- Continue with medications as above

5. Hyperlipidemia

-LDL 95, goal less than 70

-Continue atorvastatin 40 mg daily, not previously taking any statin -Repeat lipid panel in 3 months

6. Diabetes mellitus, type 2- Uncontrolled diabetes with A1c 9.5

-Will refer to endocrinology

7. CKD (chronic kidney disease) -Most recent CR 1.82, EGFR 42

-Will refer to nephrology

Follow Up 3 months

History of Present Illness:

59-year-old male with past medical history of nonischemic cardiomyopathy, HFrEF 25 to 30%, nonobstructive CAD, hypertension, hyperlipidemia, type 2 diabetes, CKD, obesity.

Patient recent hospitalized on 12/25/2023 with acute on chronic decompensated heart failure exacerbation.

Presenting today for post hospital follow-up.

Patient still found to be mildly hypervolemic but greatly improved since hospital discharge with 30 pound weight loss. Referred for sleep medicine for OSA evaluation.

Patient reports she has been doing well.

Denies any significant shortness of breath, dyspnea on exertion, chest pains, worsening lower extremity edema, PND, orthopnea

Reports compliance with all medications

For BP log provided blood pressures have remained stable, has shown consistent weight loss since hospital admission.

Mentions that prior to recent hospital admission he had been off all GDMT since COVID pandemic started

Mostly lost to follow-up in general over past couple years.

Current cardiac medications: Aspirin 81 mg daily

Atorvastatin 40 mg daily

Bumex 2 mg twice daily

Carvedilol 12.5 mg twice daily Dapagliflozin 10 mg daily Hydralazine 50 mg twice daily Isosorbide mononitrate 60 mg daily

Pertinent labs reviewed:

BMP 12/31/2023: NA 136, K3.3, CR 1.82, EGFR 42 A1c12/24/2023: 9.5

Lipid panel 12/24/2023: TC 151, LDL 95, HDL 40, trig 81

Decrease Bumex to 2 mg daily. Continue medications and follow up in 3 months.

Patient #7

Chief Complaint:

New patient redo AVR/MVR: 69-year-old female with a history of aortic stenosis, mitral regurgitation, atrial fibrillation, CAD, tachy-brady syndrome, cardiac pacemaker, hypertensive disorder, hyperlipidemia, and CVA. Cath 12/20/23, CT CHEST 11/16/23.

Assessment/Plan:

1. Aortic stenosis

Patient presented to the office today after surgical evaluation. Patient was seen and evaluated, all pertinent diagnostic films were reviewed including cardiac catheterization, TEE, chest CT and not limited to those. After review of films and examination of the patient, patient is an active 69-year-old. Patient presented options for intervention to patient and her son. The first option is medical management, the second option is redo aortic valve replacement and mitral valve replacement via sternotomy and the third option was staged intervention, which would include TAVR and reevaluation after TAVR procedure to evaluate symptoms. If patient remains symptomatic after TAVR procedure, then patient could be considered for a redo minimally invasive mitral valve replacement post TAVR. If patient remained asymptomatic after TAVR procedure, then no mitral valve intervention would be needed and patient could be observed from a cardiology standpoint. All 3 options were presented to the patient and her son in the office. We will order further workup including TAVR CTA, ultrasound of the lower extremities to rule out DVT and request pulmonary clearance and PFTs from her pulmonologist.

Patient will be presented in the heart team meeting to be discussed in the valve clinic with clinical cardiologist and the multidisciplinary care team.

2. Mitral regurgitation

3. Tricuspid regurgitation

History of Present Illness:

Mrs. F comes in today for surgical evaluation of multi valvular disease including bioprosthetic aortic valve stenosis, bioprosthetic severe mitral valve regurgitation, and moderate to severe tricuspid regurgitation. She is a 69-year-old African-American woman with a complex past medical history with hypertension, hyperlipidemia, CVA w/ no motor deficits, AVR (SAVR with 21mm Magna valve 5/2013) and MVR (MVR 27mm Magna valve 5/2013) with Dr.B, tachycardia-bradycardia syndrome s/p Micra PPM placed January 2019, persistent A-fib on warfarin, and COPD/ASTHMA (Patient is on inhalers). Patient follows with pulmonologist Dr. M. Patient’s clinical cardiologist Dr. L. Patient has good dental health, she routinely goes to the dentist, she recently went in October and underwent dental work including some fillings for cavities. She has nothing painful or hurting, but she is pending some dental work for further cavities and fillings.

Surgical history: Aortic valve replacement (5/2013), mitral valve replacement (5/2013), hysterectomy, tubal ligation, Micra PPM (1/2019).

Social history: Patient denies alcohol abuse, recreational drug use, tobacco use

Family history: Denies premature coronary artery disease, valvular disease, open heart surgery

Current medication regimen: Hydrochlorothiazide, Protonix, Symbicort, Trelegy Ellipta, Coumadin.

Today, patient accompanied by by her family. Reports having symptoms of chest pain.

The patient remains compliant to their current medical regimen. Denies any exertional limitations or symptoms. At this time, the patient denies any chest pain, palpitations, paroxysmal nocturnal dyspnea, orthopnea, dizziness, lightheadedness, syncope or near-syncope.

All questions were answered and plan of care was explained to the patient and her son in great detail. We will continue to follow and formulate an appropriate plan of care once further workup has been completed. Patient will also need to complete further dental work prior to any surgical intervention. Patient is currently on Coumadin, will need to be evaluated prior to any surgical intervention. Discussed with patient non-opioid alternatives for pain treatment. Discussed the advantages and disadvantages of the use of non-opioid alternatives. Patient provided non-opioid alternative educational pamphlet. Non-opioid alternatives considered were acetaminophen, ibuprofen, ketorolac, tramadol, and gabapentin.

Patient #8

Chief Complaint:

Chest pain.

Assessment/Plan:

1. Dyspnea on exertion

Cardiac catheterization with LHC + RHC from 6/28/2023 reviewed and shows no significant CAD, normal filling pressures, normal pulmonary pressures and normal CO/CI.

Last echo 7/16/2022:

EF 45-50%, moderate MS, moderate TR, severe biatrial enlargement.

NM Stress MPI 10/17/2022:

The left ventricle is normal in size with no transient dilatation. There is a mild fixed anterior defect at both rest and stress. Evidence of nondilated nonischemic cardiomyopathy with breast attenuation and paradoxical septal wall motion and ejection fraction mildly decreased at 45 percent.

V/Q Scan 10/12/2022:

Low probability for pulmonary embolism.

Her symptoms of chest pain (sharp) and dyspnea are likely related to increase psychosocial stressors at home with her husband. Alternatively, GI etiologies should be considered.

2. Chronic atrial fibrillation- Labs reviewed from 10/2/23 show INR 2.4.

3. Chronic diastolic heart failure

Continue GDMT for HF including carvedilol 12.5 mg twice daily, dapagliflozin 10 mg daily, Aldactone 25 mg daily. Unable to tolerate afterload reduction due to borderline BP.

Labs from April 21, 2023 reviewed and show creatinine 1.0, potassium 4.4, CO2 27, hemoglobin A1c 6.1%, LDL 73 mg/dL, triglycerides 103 mg/dL, HDL 50 mg/dL.

4. Left carotid artery stenosis

On previous hospital admission in 2022, she was placed in a neurology ward for close neurological monitoring. The interventional neuroradiology service was consulted. Although a CTA of the head and neck did show left internal carotid artery stenosis, this was also seen on review of previous imaging from 2017. Consequently, the interventional neuro-radiology service recommended medical management but no endovascular intervention or diagnostic studies.

5. S/P mitral valve open commissurotomy- History of mitral valve commissurotomy in 1987.

Patient Instructions:

– Eat more fruits and vegetables and other high-fiber foods. – Choose foods that are low in saturated fat and trans fat.

– Eat at least two servings of fish each week. Oily fish, which contain omega-3fatty acids, are best. These fish include salmon, mackerel, lake trout, herring, and sardines. If you cannot eat fish, you can also get omega-3 fats from omega-3 eggs, walnuts, flax seeds, and canola oil.

– Limit sodium, alcohol, and added sugar.

– Perform 150 minutes of moderate intensity exercise (e.g., brisk walking) per week (for example, 30 minutes a day, 5 days a week) or 75 minutes of vigorous intensity exercise (e.g., jogging or running) per week

– Muscle-strengthening activities on 2 or more days a week that work all major muscle groups (legs, hips, back, abdomen, chest, shoulders, and arms).

Plan: Discussed the option of transitioning patient from carvedilol to Toprol-XL in order to allow for initiation of Entresto or ARB.

Patient #9

Chief Complaint:

Returning warfarin patient for follow up.

To restart on warfarin after failed eliquis by a thrombus to LV.

Assessment/Plan

1. Diabetes mellitus

2. Chronic systolic heart failure

3. Left ventricular thrombosis

4. Left ventricular aneurysm

5. Mixed hyperlipidemia

6. Anticoagulation on warfarin

History of Present Illness:

Pt came to the clinic as a returning pt for bridging to warfarin. Pt with a recent Dx of Left Ventricular Thrombus while on eliquis. She was referred to the clinic by Dr. M. Pt’s thrombus had decreased in size but still present to Left Ventricular Apical Area. Pt last dose of Eliquis yesterday at 8 pm, due to the occurrence of thrombosis while on Eliquis, stopped her Eliquis, started on lovenox 90 mg every 12 hours and warfarin 7.5 mg x 2 days then 5 mg on Saturday and daily until Tuesday when he is coming to check his INR. Lovenox first dose given in the office. Pt. was seen in clinic previously and was taking warfarin 7.5 mg daily and INR stable, but now is taking Plavix. He was instructed to keep consistency on his Vitamin K intake and to contact us if any bleeding, changes on meds or diet. Pt’s plan of care established in collaboration with Dr. H.