Chief complain: suddenly short of breath noted on this morning
Present illness:
The 72 year-old male patient who is a retired 酒家boss is a case with history of 1.CHF 2. Essential hypertension with poor control for 3-4 years 3. Type 2 DM diagnosed on 87- Nov 4. Chronic pleural effusion for 3-4 years. One week before admission, he got nause, vomiting, epigastralgia, and cough with yellowish sputum, so he came to LMD for help. Where he prescribed some medication and IV for symptoms relief. However, dyspnea and pitting edema developed, poor appetite and general malaise were also noted. He denied fever, chillness, chest pain or chest tightness. This morning, due to suddenly dyspnea, he was brought to our ER for help. Besides dyspnea, whole body shaking, cold sweating, and pale face were also noted. CxR at ER revealed cardiomegaly and pulmonary edema and pleural effusion; EKG revealed RBBB, so he admitted to our ward for further management.
Dr Buttrey’s questions and comments: (I did not attempt to rewrite this history because so much information was missing.)
Has he ever had similar symptoms before, i.e., sudden SOB like the day of admission and/or the N/V & epigastric distress of 1 wk earlier? Any previous hx of ankle edema?
When was CHF diagnosed? What is his normal level of functioning? (NYHA class?)
What has been thought about his pleural effusion? Was the effusion on the ER CXR about the same as before or had it changed?
Has he been taking his medications regularly and/or changed the way he takes them? Does he follow any diet, e.g., low-salt, and, if so, any changes? Did anything unusual or upsetting occur before he started feeling sick 1 wk PTA? Has his BP been unusually high lately?
Any palpitation?
How did the ER EKG compare with previous EKG’s in his old chart? Any known hx of MI?
Any known hx of lung disease (other than the pleural effusion, which has yet to be explained).
Hx of smoking, hyperlipidemia, sedentary lifestyle, FH of CAD?
Don’t list all his previous diagnoses in the first sentence of the HPI. (I know this is the way it’s usually been done, but it’s not a helpful habit.) In this case, where the CHF and/or HTN may be important parts of the PI, it’s fine to mention them first. But we need to know much more about them in order to see if and how they relate to the current symptoms. I don’t think the DM is directly related, though it is a risk factor for CV disease, or he might have diabetic cardiomyopathy. I would mention it toward the end when listing other CAD risk factors and write “(see PMH)” immediately after it. Then in the PMH, it should be described fully, especially noting whether he has other complications of DM.
His symptoms sound as if they most likely relate to heart disease, either an ACS (with an MI possibly occurring as early as 1 wk PTA) or worsening of his CHF. But much more needs to be clarified about his usual level of functioning plus any factors that might cause worsening of his underlying disease. Assuming he has been followed in our OPD, the HPI should also include comparison of the ER CXR and EKG with those done previously. Another possible cause of acute pulmonary edema is uremia. If you already know he’s not uremic, you wouldn’t necessarily mention renal disease in the HPI. If you had no data on his renal function, however, you ought to at least note whether he’s known to have renal insufficiency.