You are working in the internal medicine clinic of a large teaching hospital. Today your first patient is 70-year-old J.M., a man who has been coming to the clinic for several years for management of coronary artery disease (CAD) and hypertension (HTN)
A cardiac catheterization done a year ago showed 50%
stenosis of the circumflex coronary artery. He has had episodes of dizziness for the past 6 months and
orthostatic hypotension, shoulder discomfort, and decreased exercise tolerance for the past 2 months.
On his last clinic visit 3 weeks ago, a chest x-ray (CXR) examination revealed cardiomegaly, and a 12-lead
electrocardiogram (ECG) showed sinus tachycardia with left bundle branch block (LBBB). You review J.M.'s
morning blood work and initial assessment.
Laboratory Results
Chemistry
Sodium 142 mEq/L
Chloride 95 mEq/L
Potassium 3.9 mEq/L
Creatinine 0.8 mg/dL
Glucose 82 mg/dL
BUN 19 mg/dL
Complete Blood Count
WBC 5400/mm3
Hgb 11.5 g/dL
Hct 37%
Platelets 229,000/mm3
Initial Assessment
Complains of increased fatigue and shortness of breath, especially with activity, and "waking up
gasping for breath" at night, for the past 2 days.
Vital Signs
Temperature 97.9 ° F (36.6 ° C)
Blood pressure (BP) 142/83 mm Hg
Heart rate 105 beats//min
Respiratory rate 18 breaths/min
As you review these results, which ones are of possible concern, and why?
The blood pressure and pulse are slightly elevated, with several possibilities, including worsening of
J.M.'s CAD, HTN, or possibly heart failure (HF). More testing is needed to verify. His Hgb and Hct are
slightly decreased, and further testing is needed to determine whether an iron deficiency or vitamin
B12 deficiency exists.
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