Metabolic and Cardiac

Patient Profile

Name: Cat Stevorski

Age: 72 years old

Gender: female

History of Present Illness

C.T. is a 72-year-old woman who presents with increasing fatigue, occasional palpitations, and mild swelling in her ankles.

Past Medical History

• Hypertension
• Type 2 Diabetes Mellitus (T2DM) HbA1c: 7.5%
• Atrial Fibrillation (AF) diagnosed 3 years ago
• Osteoporosis

Social History

• Retired accountant
• Single
• Volunteers for Meals on Wheels
  Consumes alcohol 1x/month
• No drug or tobacco use

Current Medications

• Metformin 1000 mg twice daily
• Lisinopril 20 mg daily
• Apixaban 5 mg twice daily
• Alendronate 70 mg weekly

Physical Assessment

General Appearance: Ms. Stevorski is alert and oriented to person, place, and time. Her overall appearance suggests mild discomfort and fatigue. She has a slightly stooped posture.

Vitals

• Blood Pressure: 138/82 mm Hg (right arm, seated position)
• Heart Rate: 84 bpm, irregularly irregular
• Respiratory Rate: 18 bpm
• Temperature: 97.9°F (36.6°C) (oral)
• Oxygen Saturation: 96% on room air

Cardiovascular Examination

• Jugular venous pressure (JVP) is slightly elevated at 4 cm above the sternal angle in a 30-degree position. No visible carotid pulsations or abnormal pulsations in the chest wall.
• Mild bilateral ankle edema is noted.
• Apical impulse is displaced laterally and diffuse, suggesting left ventricular enlargement.
• Peripheral pulses:
  • Carotid: 2+ bilaterally, no bruits
  • Radial: 2+ bilaterally, irregularly irregular
  • Femoral: 1+ bilaterally
  • Dorsalis pedis: 1+ bilaterally
  • Posterior tibial: 1+ bilaterally
  • Capillary refill time is 3 seconds in both feet, slightly delayed
  • Heart sounds: S1 and S2 are irregular in rhythm, consistent with AF. A soft (grade 2/6) systolic murmur is heard at the apex, radiating to the axilla, suggestive of mitral valve regurgitation. No S3 or S4 gallop is appreciated

Respiratory Examination

• Lung fields are clear to auscultation bilaterally, with no rales or wheezes.
• Chest expansion is symmetric.
• No use of accessory muscles for breathing.
• Percussion reveals resonance throughout all lung fields.
• Breath sounds are vesicular and equal bilaterally, without adventitious sounds.

Abdominal Examination

• Abdomen is soft, non-tender, and non-distended.
• No hepatomegaly or splenomegaly is appreciated.
• No abdominal bruits are auscultated.

Neurological Examination

• Cranial nerves II-XII are grossly intact.
• Motor strength is 5/5 in all extremities.
• Deep tendon reflexes are +2 in upper extremities and +1 in lower extremities.
• Sensation to light touch and pinprick is diminished in a stocking distribution bilaterally.
• Proprioception is intact in the upper extremities but diminished in the toes.
• Romberg test is positive.

Musculoskeletal Examination

• Mild kyphosis of the thoracic spine is observed.
• Range of motion in the cervical and lumbar spine is limited and accompanied by discomfort.
• No joint swelling, erythema, or warmth is noted in the peripheral joints.
• Mild tenderness is elicited on palpation of the thoracic spine.

Skin Examination

• Skin is warm and dry with normal turgor.
• No rashes, lesions, or ulcerations are observed.
• There is no evidence of acanthosis nigricans.

Foot Examination

• Mild callus formation is noted on the plantar surface of both feet.
• No open wounds or ulcerations are present.
• Monofilament testing reveals decreased sensation in both feet.

Ophthalmologic Examination

• Visual acuity is 20/40 in both eyes with corrective lenses.
• Fundoscopic examination report indicates mild arteriolar narrowing and arteriovenous nicking.
• No evidence of diabetic retinopathy is observed at this time.

Diagnosis

• AF: Confirmed by irregularly irregular heart rhythm on examination and previous diagnosis.
• Hypertension: Currently controlled with medication, but requires ongoing management.
• T2DM: Suboptimal control based on HbA1c of 7.5% and evidence of diabetic neuropathy.
• Osteoporosis: Previously diagnosed, with physical examination findings consistent with the condition.
• Early Signs of Heart Failure: Suggested by mild ankle edema, elevated JVP, and displaced apical impulse.
• Mitral Regurgitation: Indicated by the systolic murmur heard on auscultation.
• Peripheral Arterial Disease: Suggested by diminished peripheral pulses in the lower extremities.
• Diabetic Peripheral Neuropathy: Evidenced by diminished sensation and absent ankle reflexes.
• Hypertensive Retinopathy: Mild changes observed on fundoscopic examination.

Treatment Plan

AF Management

• Anticoagulation: Continue apixaban 5 mg twice daily for stroke prevention.
• Rate Control: Initiate metoprolol 25 mg twice daily for rate control.
• Monitoring: Schedule regular electrocardiogram (ECG) monitoring to assess AF burden and effectiveness of rate/rhythm control. Consider home monitoring with wearable devices if appropriate for the patient.

Hypertension Management

• Medication: Continue lisinopril 20 mg daily, may increase if blood pressure remains above target after 2-4 weeks.
• Home Blood Pressure Monitoring: Encourage home blood pressure monitoring and maintain a log.
• Lifestyle Modifications: Recommend sodium restriction (<2300 mg/day) and adoption of the dietary approaches to stop hypertension (DASH) diet, with physical activity as tolerated.

T2DM Management

• Glycemic Target: Set an individualized HbA1c target of <7.5% to balance glycemic control with the risk of hypoglycemia.
• Medication: Continue metformin 1000 mg twice daily.
  • Add an SGLT2 inhibitor (e.g., empagliflozin 10 mg daily) as a second-line agent.
• Blood Glucose Monitoring: Implement a structured self-monitoring blood glucose plan. Educate on recognition and management of hypoglycemia. Focus on nutrition, foot care, and the importance of glycemic control in preventing complications.
• Screening:
  • Schedule annual comprehensive foot exams and eye examinations.
  • Monitor renal function and urine albumin-to-creatinine ratio regularly.

Osteoporosis Management

• Medication: Continue alendronate 70 mg weekly. Ensure adequate calcium (1200 mg/day) and vitamin D (800-1000 IU/day) supplementation.
• Fall Prevention: Implement a multifactorial fall prevention program, including:
  • Home safety assessment and modification.
  • Balance and strength training exercises.
  • Review of medications that may increase fall risk.
• Bone Density Monitoring: Schedule a follow-up DXA scan to assess treatment efficacy and monitor for progression.
• Physical Therapy: Refer for physical therapy to improve posture, spinal mobility, and overall strength.

Heart Failure Prevention and Management

• Diagnostic Evaluation: Echocardiogram to assess left ventricular function, valvular status, and confirm the presence of mitral regurgitation. Measure B-type natriuretic peptide (BNP) levels to aid in diagnosis and prognosis.
• Medication Optimization: The current regimen of lisinopril and planned addition of metoprolol aligns with heart failure management.
• Fluid Management: Educate on daily weight monitoring and when to report changes. Recommend sodium and fluid restriction if heart failure is confirmed.
• Multidisciplinary Team: Continue communication and collaboration between cardiology, endocrinology, and PCP.