Dr notes from my last and new PCP visit

[Guest guest]

As I posted before about this visit this PCP has no clue about PA. You will

also note LVH Doesn't seem to be a concern for him. Has no relationship to

shortness of breath.

LOCAL TITLE: Primary Care Clinic

STANDARD TITLE: PRIMARY CARE NOTE

DATE OF NOTE: OCT 27, 2011@13:34

AUTHOR: TAYLOR,DEAN J

URGENCY:

Note

ENTRY DATE: OCT 27, 2011@13:35

EXP COSIGNER: GROSSMAN,ALEXANDRA

STATUS: COMPLETED

Printed at WHITE RIVER JCT VAMROC

*** Primary Care Clinic Note Has ADDENDA ***

Chief Complaint: 1.) Chronic shortness of breath 2.) " Brain fog "

HPI:

This is a morbidly obese (BMI 45) 64 yo male with pmhx notable for HTN, OSA and

BPV presenting with dyspnea on exertion that has been ongoing for 6 weeks and

prompted a visit to the ED on 9/24/11. In the ED he was worked up with negative

CE's, negative CXR and EKG notable only for LVH. He has had intermittent

episodes of DOE for the past 6 years and has had an extensive cardiac work-up

including ETT X 3 most recently 2/2011 that was notable only for decreased

functional capacity (58% of expected). He states that his DOE has not improved

much since he was seen in the ED and that he gets sob with walking short

distances. Prior to this most recent episode of DOE he developed vertigo type

symptoms that lasted for a week but have since resolved. He denies any cp,

palpitations, PND, orthopnea or sob at rest. He states that " breathing into a

paper bag " does help his sob and he feels that he has " Conns syndrome " . I

explained that hyperaldosteronism is very rare and that he would have low

pottasium and a higher blood pressure if he had Conns.

He is also c/o chronic fatigue, lightheadedness and " brain fog " that also

started about 6 years ago. He endorses compliance with his BiPap. He has

gained 28 pounds in the last 6 years. He exercises very little 2/2 decreased

tolerance.

ROS:

Cons- Denies fevers, chills or unintentional weight loss

Skin- Denies any new rashes, sores or ulcers

PATIENT NAME AND ADDRESS (Mechanical imprinting, if available) VISTA Electronic

Medical Documentation

BILL, FRANCIS HENRY

HEENT- Denies any vision changes, ringing in ears or sore throat

CV- Denies any chest pain or palpitations

Resp- + for SOB as above

GI- Denies any abdominal pain, changes in bowel habits or blood in stool

GU- Denies any dysuria or obstructive symptoms

MSK- Denies any arthralgias or myalgias

Hem- Denies any easy bruising or bleeding

Endo- Denies any cold or heat intolerance

Neuro- Denies any weakness, numbness or tingling

Pmhx:

# Morbid obesity

- BMI of 45

# Hypertension

# DOE

- ETT- 4/10/2009: Negative for ischemia, Functional capacity 58% of expected

- ECHO- 5/19/2008: EF of 55-60%, No obvious WMA

- PFT's 11/2005: Normal spirometry

# Dizziness and tachycardia

- see neuro consultation 5/16/06

- 6/06 CT= frontal atrophy of brain

- 9/05 ETT- 6 mets, negative

10/05 holter- rare PACSi freq islated PVCSi underlying rhythm sinus averaging

71

- 11/05 PFTs- normal spirometry

- 11/05 carotid studies- minimal stenosis

-11/05 loop monitor- sypmtoms sometimes with sinus tach, someties with NSR

- 12/05 echocardiogram normal

- 12/08 MRI of brain- mild to moderate cerebral atrophy.

# Chronic fatigue

# Hearing loss/tinnitus

# RLL lung nodule

- CT of chest 12/06= 7 mm RLL nodule

- followup CT 5/08= stable

# L adrenal adenoma

- CT of chest 12/06- L adrenal nodule, likely adenoma

- 8/7/06 VMA normal

- 2/23/06 serum cortisol (random) normal

- 11/09- stable appearance

# Sleep apnea, on CPAP

- Sleep study- 3/21/2007 -> probable sleep apnea

# Hepatic cysts

# Stable hyperdense cyst L kidney on 11/09 CT

# sip laparoscopic appendectomy 12/14/D8

Meds:

Active Outpatient Medications (excluding Supplies) :

Active Outpatient Medications

1) FUROSEMIDE 20MG TAB TAKE THREE TABLETS BY MOUTH EVERY ACTIVE

DAY TO REMOVE FLUID/CONTROL BLOOD PRESSURE

2) POTASSIUM CHLORIDE 10MEQ SA TAB TAKE TWO TABLETS BY ACTIVE

MOUTH EVERY DAY TO SUPPLEMENT POTASSIUM

Active Non-VA Medications

Non-VA ASPIRIN 325MG TAB 325MG MOUTH EVERY DAY

Non-VA FISH OIL CAP/TAB 2 EVERY DAY

Non-VA MULTIVITAMIN/MINERALS TAB 1 MOUTH EVERY DAY

5 Total Medications

Allergies:

DILTIAZEM

Symptoms: DIZZINESS

(historical)

Sochx:

Pt lives by himself in Enfield. He worked at Hitchcock hospital in the

boiler-room for 15 years and later worked as a gardener and handyman. He is now

on disability. He denies any tobacco or ETOH use. He exercises very rarely and

states that he eats sensibly but does occasionally eat junk food.

Vitals:

DATE/TIME

10/27/11 @ 1323

95% on RA

TEMP

99.4

PULSE

80

RESP

BP

142/73

PAIN

o

WEIGHT

308

Physical exam:

Gen: Obese male in NAD

Skin: No rashes, sores or ulcers

HEENT: EOMI, PERRL, poor dentition, op clear with mmm

Neck: Supple with normal ROM, JVD not appreciated

CV: RRR without murmur

Pulm: CTAB without wheezes, rales or rhonchi. SOB with getting up to the exam

table.

Abd: Obese, S/NT/ND, NABS, No HSM

Ext: 1+ and equal DPP BL, 1+ pretibial pitting edema bl

Neuro: Non-focal, moving all 4 extremities equally

Labs:

CBC:

WBC: 7.4 (09/24/11 15:15)

HCT: 44.0 (09/24/1115:15)

HGB: 14.9 (09/24/11 15:15)

PT : 12.2 (09/24/11 15: 15)

BMP:

GLU,BUN,CREAT,LYTES GLUCOSE BUN CREAT SODIUM K CHLOR CO2

9/24/11 15: 15 131 H 11 0.91 140 3.9 107 23

GLU, BUN,CREAT,LYTES ANION eGFR

9/24/11 15: 15 10 84

A/P:

This is a 64 yo morbidly obese male with HTN, OSA, and chronic DOE with

extensive negative cardiac workup. I had a frank discussion with the pt

regarding his obesity and how it is contributing to his decreased functional

status and the likely cause of most of his symptoms. Pt seems a bit unwilling

to accept this and thinks that his symptoms might be 2/2 hyperaldosterinism and

mentioned talking to a specialist here at the VA. I assured him that it was

very unlikely that he had hyperaldo and described to him why. He may benefit

from talking to a health psychologist and was introduced to Glenna. In regards

to his HTN, we did discontinue his atenolol as it may be worsening his fatigue.

He was started on lisinopril and scheduled for a BP clinic appt in 2 weeks.

# DOE 2/2 deconditioning/obesity

- Encouraged pt to exercise daily as tolerated

# HTN

- Stop Atenolol

- Start lisinopril 5 mg qd

- F/u at BP clinic in 2 weeks with lytes drawn

# LE edema

- Continue lasix 60 mg QD

- Continue triamterene 50 mg QD

#Preventative

- Flu shot today

Colonoscopy ordered

HIV ordered

Lipid panel ordered

Hgb A1C ordered

RTC in 4 months

Patient seen and discussed with Dr. Grosssman who agrees with plan of care

Dean , PGY-1

BP>=140/90 or BP>=130/80 + DM:

Repeat BP: 136/75

The patient's medication regimen was adjusted to improve BP control.

The patient was counseled on the importance of regular exercise

and/or physical activity in the control of blood pressure.

The patient was instructed to try to exercise at least 30 minutes

3 times per week if possible and that any increase in physical

activity may be useful in controlling BP.

The patient has a limited ability to exercise but was encouraged

to increase physical activity as much as possible since any

increase in activity may be beneficial in improving BP control.

The patient was counseled on the importance of diet and weight

control in the control of blood pressure.

Co1orectal Cancer Screening:

Patient is scheduled for a colonoscopy.

HIV Screening

Patient has given verbal consent for HIV antibody testing, and written

educational materials have been provided. An order for an HIV Antibody

test has been entered - see orders tab.

Home Telehealth (CCHT) Referral:

Patient declines participation in CCHT Program at this time.

Lipid Screening(M):

Lipid profile ordered.

/es/ DEAN J TAYLOR

Resident MD

Signed: 10/27/2011 17:17

/es/ ALEXANDRA GROSSMAN

Staff MD

Cosigned: 10/30/2011 20:22

Receipt Acknowledged By:

12/02/2011 16:13 /es/ GLENNA S ROUSSEAU

Clinical Psychologist

10/30/2011 ADDENDUM STATUS: COMPLETED

I discussed this patient with Dr. and agree with his assessment and plan.

/es/ ALEXANDRA GROSSMAN

Staff MD

Signed: 10/30/2011 20:22

LOCAL TITLE: Telephone Note-Primary Care

STANDARD TITLE: PRIMARY CARE TELEPHONE ENCOUNTER NOTE

DATE OF NOTE: SEP 26, 2011@09:14 ENTRY DATE: SEP 26, 2011@09:14:07

AUTHOR: DATTILIO, LINDA EXP COSIGNER:

Letter about labs

Your hemoglobin A1C is a measure of your long-term blood sugar control. Your

A1C was 5.7, indicating pretty good blood sugar management.

Your cholesterol levels were very good:

CHOL: 200

HDL: 43

LDL: 128

TRIG: 145

HDL is the good cholesterol and should be greater than 40 which yours is.

Triglycerides are a type of bad cholesterol and should be less than 150 which

yours is.

LDL is the bad cholesterol and should be less than 130 which yours is.

Don't forget that you have a blood pressure check on November 10th. You should

get your blood drawn prior to that appointment. I hope changing your blood

pressure medication improves your energy.

Wishing you the best of health,

Dean , DO

VA Medical Center, White River Junction, VT

/es/ DEAN J TAYLOR

Resident MD

Signed: 10/31/2011 13:58

/es/ ALEXANDRA GROSSMAN

Staff MD

Cosigned: 11/03/2011 16:14

64 M NH vet with HTN Possable since 1966 but most B/P at that time were normal a

few with top 140, K went to 3.2 with HCTZ (2007). Sx of CHF. CT 2 cm L adrenal

adenoma(2006). Aldo Renin not classic for PA but done on meds. Never tried on

spiro or eplere but trying to get VA to try. B/P is arould 140/80 on diuretics

eating less NA not at DASH goal. Normal Echo and stress tests.