General Information: GY is a 70 years old White American male at the emergency department of NYP Medical
Center with multiple complications.
CC: “I feel weakness and difficulty of breathing”.
HPI: GY is a 70 years old male presents to the emergency department with multiple complications. He has not
felt well last couple of weeks and lost appetite and lost weight 15 lb in the last month. GY has diabetic
nephropathy which has progressed to ESRD for 10 years. He has renal failure and has been on hemodialysis
for 5 years (2 times/week). He has history of coronary heart disease for last 10 years, COPD for last 15 years
and abnormality in secretion of corticosteroid hormone from birth. He occasionally feels pain in his chest which
disappears after taking nitroglycerine sublingual tablet or rest. He complains shortness of breath and becomes
weak after walking several blocks.
PMH: Ischemic Heart Disease X 10 years and controlled by medication
Chronic Obstructive Pulmonary Disease X 15 years and uncontrolled
Adrenal insufficiency X from birth
FH: Mother died at the age of 90 from diabetes.
Father died of heart attach at the age of 75.
He has no siblings.
SH: Ethanol drinking with 2 beers x daily, he smokes 1 pack of cigarettes daily, he is single and live in
Meds: Nitroglycerine SL 0.4 mg prn for chest pain
Atenolol 50 mg po qd
Levalbuterol neb 0.63 mg tid every 6 hours
Ipratropium neb 500 mcg every 6 hours
Lipitor 10 mg po daily
Prednisone 5 mg po daily
Glyburide 10 mg po daily
Furosemide 40 mg po daily
PE: VS: BP 130/74 P 79 RR 18, T 98ºF, Wt 62 kg, Ht 5’8”
CHEST: RRR, no murmur, rales bilaterally chest wall NT.
CV: S1 S2 normal, no chest pain, no palpitation, no shortness of breath
Abd: No bruits tenderness, no masses.
Skin: Rash at lower extremities
HEENT: No history of headaches, dysphasia or odonyphasia
Mental status: Normal.
Labs: Na 135; K 4.3; Cl 102; CO2 24; BUN 27 (H); Scr 2.1 (H); Glu 170 (H); ALT 26; AST 21; total Chol 175;
LDL 120; HDL 39; TG 115; Albumin 4.8; Hgb 18; Hct 43% RBC 5.6; WBC 9; Plt 250, A1C 9.0, DST 450.
Problem List: 01. Coronary Heart Disease (CHD)
- Chronic Kidney Disease (CKD)
- Chronic Obstructive Pulmonary Disease (COPD)
- Adrenal Insufficiency
- Coronary Heart Disease (CHD)
S: GY is a 70 year old male who is suffering from coronary heart disease from last 10 years. He complains
weakness and difficulty of breathing. He occasionally feels pain in his chest which disappears after taking
nitroglycerine sublingual tablet or rest. He drinks beer and smokes regularly.
O: Age 70; BP 130/74 P 79 RR 18; ALT 26; AST 21; total Chol 175; LDL 120; HDL 39; TG 115; Hgb 18; Hct
43% RBC 5.6