tokens: Admission Date : 2016-07-18 Discharge Date : 2016-07-21 Date of Birth : 1969-11-05 Sex : M Service : MEDICINE Allergies : Penicillins Attending : Daniel Z. H. Walton , M.D. Chief Complaint : Dyspnea Major Surgical or Invasive Procedure : None History of Present Illness : 46 - yo-man w/ active cocaine use presents w/ LE edema . 10 days ago , he developed b/l LE edema that has gotten progressively worse until now . Three days ago , he developed dyspnea on exertion when climbing stairs , assoc w/ 2-pillow orthopnea and PND . He denies any recent chest pain , palpitations , headache , confusion , weakness , numbness , abd pain , or hematuria . No recent viral syndromes or URI s. He does admit to cocaine use last night . Today , his wife convinced him to present to the Deanna for evaluation . In the Deanna , his BP was 230/170 . BNP was elevated at 7500 . CXR revealed evidence of cardiomegaly and pulm edema . He was treated w/ ASA 325 mg , lasix 10 mg IV , and hydralazine 10 mg IV x 2 . He responded well to lasix w/ good UOP , but diastolic BP remained elevated at 170 , prompting initiation of nitroprusside gtt . He is now admitted to the CCU for further care . Past Medical History : none Social History : significant for current tobacco use . Drinks 3-4 beers a few times weekly , no h/o withdrawal symptoms , seizures or DT s. Snorts cocaine 1-2 times monthly . Never injected drugs . Family History : There is no family history of premature coronary artery disease or sudden death . Physical Exam : VS : T, BP 181/122 , HR 84 , RR 12 , O2 98% 2L/m Gen : lying flat in bed , pleasant and conversational , NAD HEENT : NCAT . Sclera anicteric . PERRL , EOMI . OP clear w/ MMM . Neck : Supple with JVP of 8 cm . CV : reg s1 , loud s2 , + 2/6 systolic murmur radiating to axilla , no s3/s4/r Pulm : CTA b/l w/ no crackles or wheezing Abd : obese , +BS , soft , NTND . Ext : warm , 2+ DP b/l , 2+ pitting edema to knees b/l Neuro : a/o x 3 , CN 04-04 intact Pertinent Results : 2016-07-18 05:30 PM WBC - 7.7 RBC - 5.00 HGB - 15.0 HCT - 42.8 MCV - 86 MCH - 30.0 MCHC - 35.0 RDW - 14.6 2016-07-18 05:30 PM PLT COUNT - 315 2016-07-18 05:30 PM CK-MB - 4 proBNP - 7489 * 2016-07-18 05:30 PM cTropnT - 0.02 * 2016-07-18 05:30 PM ALT(SGPT) - 77 * AST(SGOT) - 60 * CK(CPK) - 195 * ALK PHOS - 104 AMYLASE - 100 TOT BILI - 0.4 EKG demonstrated NSR at 87 bpm , nl axis , nl int , LVH w/ strain pattern , no ischemic changes . CXR : Moderate to severe enlargement of the cardiac silhouette , and particularly the left atrium accompanied by pulmonary vascular congestion and mild pulmonary edema consistent with heart failure . Conclusions : The left atrium is moderately dilated . There is moderate symmetric left ventricular hypertrophy with mild cavity dilation and severe global hypokinesis . No left ventricular thrombus is seen . Tissue Doppler imaging suggests an increased left ventricular filling pressure ( PCWP > 18 mmHg ). The right ventricular cavity is mildly dilated with severe free wall hypokinesis . The aortic valve leaflets ( 3 ) are minimally thickened . No aortic stenosis or aortic regurgitation is seen . The mitral valve leaflets are structurally normal . There is no mitral valve prolapse . Mild ( 1+ ) mitral regurgitation is seen . There is moderate pulmonary artery systolic hypertension . There is a very small circumferential pericardial effusion . IMPRESSION : Moderate symmetric eft ventricular hypertrophy with severe global biventricular hypokinesis c/w diffuse process ( toxin , metabolic , cannot exclude myocarditis ; in the absence of LVH on ECG , an infiltrative process should also be considered ). Mild mitral regurgitation . Moderate pulmonary arterial hypertension . Very small circumferential pericardial effusion . Possible abnormality on the aortic valve as described above without aortic regurgitation . If clinically indicated a TEE would be better able to define an abnormality of the aortic valve . Brief Hospital Course : 46 - yo-man w/ cocaine abuse presents w/ LE edema and DOE likely from diastolic heart failure in the setting of cocaine use complicated by hypertensive urgency . Hypertensive urgency : BP 230/170 on presentation , most likely from chronic HTN exacerbated by cocaine use . No signs of end-organ damage at present except for elevated creatinine , which is more likely a chronic problem . The patient was started on labetalol and Lisinopril . His blood pressure was taken down from 230 systolic to approx 160 systolic / 100 diastolic on discharge . His lower extremity edema improved with diuresis . An echo performed on admission showed an LF EF of 25% . It is hoped with good blood pressure control and use of an ACE-I with follow up in addition to cocaine abstaining will improved his cardiac function . Renal Failure : creatinine on admission was 1.6 Likely acute hypertensive nephropathy plus probalbe long-standing hypertensive disease . discharged on ACE-I . Substance Use : Social work saw patient and counceled him regarding substance abuse . Discharged with Margaret Hallock , cardiology follow up as well as scheduled appointment with a new PCP @ Newton Health Center . Medications on Admission : none Discharge Medications : 1. Aspirin 325 mg Tablet Sig : One ( 1 ) Tablet PO DAILY ( Daily ). 2. Hydrochlorothiazide 25 mg Tablet Sig : One ( 1 ) Tablet PO DAILY ( Daily ). Disp :* 30 Tablet (s)* Refills :* 2 * 3. Labetalol 200 mg Tablet Sig : Two ( 2 ) Tablet PO BID ( 2 times a day ). Disp :* 120 Tablet (s)* Refills :* 2 * 4. Lisinopril 20 mg Tablet Sig : One ( 1 ) Tablet PO DAILY ( Daily ). Disp :* 30 Tablet (s)* Refills :* 2 * Discharge Disposition : Home Discharge Diagnosis : Primary : - hypertensive emergency - ARF - mild transaminitis likely 03-25 etoh and cocaine abuse - cocaine abuse - lower extremity edema improved Discharge Condition : well Discharge Instructions : You came in with hypertensive emergency . You were treated with medications to improve your blood pressure . Notably you were discharged on : 1. Lisinopril 20 mg daily 2. HCTZ 25 mg daily 3. Labetalol 400 mg bid 4. ASA 162mg daily It is extremely important for you to take these medications . It is very important that you followup with your cardiology . Please return to the Deanna if you experience SOB , chest pain , fevers , chills , dizziness , decreased urine output . It is also very important that you abstain from cocaine use . Followup Instructions : Please see Dr. Villani on Monday 2016-07-25 at 10:00 in Smith 7th . It is extremely important for you to keep this appointment . You have a Primary Care Physician B. Schumacher on 07-29 @ 1:45 pm . Please arrive 1 hour prior to the appointment to complete the Free Care Application there . You need to bring a picture ID , proof of citizenship , proof of address . The Clinci phone number is ( 754 ) 280-1011 Please followup with Dr. Lesha Lefebvre on 08-15 at 10:30 am . His number is ( 532-803-1162 . His secretary can help you clarify your insurance . Ralph Katherine MD 31-164 Completed by : Terry Smith MD 12-201 2016-07-21 @ 1848 Signed electronically by : DR. Jennifer Applebee on : Sandra 2016-07-21 9:54 PM ( End of Report )