Internal Medicine Consultation Letter

Dear Dr. Sarah Jenkins Thank you for referring Mr. Arthur Pendelton, a 68-year-old gentleman, for evaluation of progressive exertional dyspnea and suboptimal glycemic control. As his primary care physician, you initiated this consultation. I had the pleasure of assessing him in person at the Vancouver General Hospital Internal Medicine Outpatient Clinic on 14/05/2024 at 10:30.

Past Medical History

1. Essential hypertension, diagnosed in 2012.
2. Type 2 diabetes mellitus, diagnosed in 2015, complicated by mild non-proliferative diabetic retinopathy (managed by Dr. Alan Chen, Ophthalmology) and microalbuminuria, with a most recent hemoglobin A1C of 8.4 %.
3. Dyslipidemia, diagnosed in 2014.
4. Chronic obstructive pulmonary disease, GOLD stage 2, diagnosed in 2019, with a measured FEV1 of 65 % predicted on spirometry in 11/2023.
5. Osteoarthritis of the bilateral knees.
6. Laparoscopic cholecystectomy in 2008.

Medications

1. Metformin (Glucophage®) 1,000 mg PO BID
2. Sitagliptin (Januvia®) 100 mg PO daily
3. Perindopril (Coversyl®) 8 mg PO daily
4. Amlodipine (Norvasc®) 5 mg PO daily
5. Atorvastatin (Lipitor®) 40 mg PO daily
6. Tiotropium (Spiriva®) 18 mcg inhaled daily
7. Salbutamol (Ventolin®) 100 mcg inhaled PRN

Allergies

1. Penicillin (maculopapular rash)
2. Sulfonamides (urticaria)

History of Presenting Illness

Mr. Pendelton presents with a four-month history of gradually worsening exertional dyspnea. Previously able to walk several city blocks without limitation, he now experiences shortness of breath after walking approximately one block on level ground or climbing a single flight of stairs. He reports mild two-pillow orthopnea over the past three weeks and progressive bilateral lower extremity edema to the mid-shins. He denies chest pain, pressure, palpitations, syncope, presyncope, paroxysmal nocturnal dyspnea, or intermittent claudication. From a respiratory standpoint, he notes a stable chronic morning cough productive of scant clear sputum, with no recent increase in volume or purulence, and no wheezing or hemoptysis.

Regarding his vascular risk factors, Mr. Pendelton monitors his blood pressure at home twice weekly, with readings averaging 145/85 mmHg. His home capillary blood glucose readings range from 8.0 to 11.5 mmol/L fasting. His physical activity has declined significantly due to his dyspnea and bilateral knee osteoarthritis. He is a former smoker, having quit five years ago after a 30 pack-year history.

Functionally, Mr. Pendelton remains independent in all basic activities of daily living and instrumental activities of daily living, though his wife has recently taken over grocery shopping due to his reduced exercise tolerance. He uses no gait aids and reports no falls. He tolerates his current medication regimen well, specifically denying orthostatic dizziness, dry cough, myalgias, or abnormal bleeding.

Review of Systems

• Constitutional symptoms: Denies fever, chills, or night sweats; reports a 3 kg unintentional weight gain over the past two months and mild afternoon fatigue.
• Cardiovascular: Positive for exertional dyspnea, two-pillow orthopnea, and bilateral pedal edema; negative for chest pain, PND, palpitations, or claudication.
• Respiratory: Positive for chronic baseline morning cough; negative for acute dyspnea at rest or wheezing.
• Gastrointestinal: Denies nausea, vomiting, abdominal pain, altered bowel habits, melena, or hematochezia.
• Genitourinary: Reports mild nocturia twice nightly; denies dysuria, hematuria, urgency, or incontinence.
• Musculoskeletal: Positive for chronic bilateral knee arthralgias; negative for acute joint swelling or myalgias.
• Neurological: Denies weakness, numbness, paresthesias, dizziness, syncope, or falls.
• Endocrine: Denies polyuria, polydipsia, or heat and cold intolerance.

Social History

Mr. Pendelton is a retired postal worker who lives in a single-level rancher home in Vancouver with his supportive wife. He smoked one pack of cigarettes daily for 30 years before quitting completely in 2019. He consumes two to three standard alcoholic beverages per week and denies any history of recreational or illicit drug use.

Family History

1. Father died at age 62 from an acute myocardial infarction and had a history of hypertension.
2. Mother died at age 81 from a cerebrovascular accident and had a history of type 2 diabetes mellitus.
3. No family history of sudden unexplained cardiac death or premature arrhythmias.

Physical Exam

• Vital Signs: BP 146/86 mmHg, HR 78 bpm and regular, RR 16 breaths/min, Temp 36.7 °C, SpO2 96 % on room air.
• General exam: Pleasant, comfortable gentleman in no acute cardiopulmonary distress, sitting comfortably on the examination table.
• Cardiovascular Exam: Normal S1 and S2 with no S3, S4, or murmurs auscultated. Jugular venous pressure is elevated at 5 cm above the sternal angle. Peripheral pulses are 2+ and symmetric throughout. There is 2+ pitting edema bilaterally extending to the mid-shins.
• Respiratory exam: Chest is clear to auscultation anteriorly and posteriorly, barring faint bibasilar crackles that do not clear with coughing. No wheezes or rhonchi.
• Abdominal exam: Soft, non-tender, non-distended, with normal bowel sounds and no hepatosplenomegaly.

Lab Investigations

10/05/2024: Hemoglobin 138 g/L, WBC 6.8 x 10^9/L, Platelets 245 x 10^9/L, Sodium 139 mmol/L, Potassium 4.4 mmol/L, Creatinine 102 umol/L, eGFR 64 mL/min/1.73m2, NT-proBNP 890 ng/L (previously 140 ng/L on 12/06/2023), Hemoglobin A1C 8.4 % (previously 7.6 % on 12/11/2023), LDL cholesterol 1.8 mmol/L (previously 2.1 mmol/L on 12/11/2023), Non-HDL cholesterol 2.3 mmol/L, Urine ACR 14.2 mg/mmol.

Imaging Investigations

1. 12/05/2024: Transthoracic echocardiogram demonstrated normal left ventricular cavity size with mild concentric left ventricular hypertrophy, preserved systolic function with an ejection fraction of 58 %, Grade 2 diastolic dysfunction, mild left atrial enlargement, and no significant valvular disease.
2. 10/05/2024: Chest radiograph demonstrated mild cardiomegaly and subtle pulmonary venous congestion without frank pulmonary edema or pleural effusions.
3. 10/05/2024: Electrocardiogram showed normal sinus rhythm at 76 bpm, normal axis, and no acute ischemic changes.

Impression

Mr. Pendelton is a 68-year-old gentleman with significant vascular risk factors who presents with clinical and biochemical features consistent with a new diagnosis of heart failure with preserved ejection fraction (HFpEF). We discussed the pathophysiology of diastolic dysfunction, the importance of volume management, and the dual benefit of sodium-glucose cotransporter-2 (SGLT2) inhibition for both his heart failure and his suboptimally controlled type 2 diabetes mellitus. We also reviewed strategies to optimize his blood pressure control.

Plan

1. Heart failure: Mr. Pendelton presents with mild volume overload secondary to heart failure with preserved ejection fraction. To achieve euvolemia, I have initiated furosemide (Lasix®) 20 mg PO daily. I counselled him on the potential adverse effects of loop diuretics, including dehydration, orthostatic hypotension, hypokalemia, and transient elevations in serum creatinine. Additionally, for disease-modifying therapy, I have prescribed empagliflozin (Jardiance®) 10 mg PO daily, which carries risks of mycotic genital infections, urinary tract infections, and volume depletion. I have advised him to restrict dietary sodium intake to less than 2 g daily, restrict fluid intake to 2 L daily, and record daily morning weights, instructing him to contact your office if his weight increases by more than 2 kg over three days.

2. Diabetes mellitus: His glycemic control has worsened, with a current hemoglobin A1C of 8.4 % against a target of less than 7.0 %. The addition of empagliflozin 10 mg PO daily will provide additional glycemic lowering alongside cardiovascular and renal protection. He will continue metformin 1,000 mg PO BID and sitagliptin 100 mg PO daily. I reviewed "sick day" medication management, instructing him to temporarily hold metformin, perindopril, furosemide, and empagliflozin during episodes of acute dehydrating illness.

3. Hypertension: His clinic and home blood pressures remain above his diabetic target of less than 130/80 mmHg. To optimize afterload reduction and blood pressure control, I have increased his amlodipine from 5 mg PO daily to 10 mg PO daily, while continuing perindopril 8 mg PO daily. I cautioned him that increasing the amlodipine dose may worsen peripheral ankle edema, though the concurrent initiation of furosemide should mitigate this effect.

4. Dyslipidemia: His lipid profile is well controlled on atorvastatin 40 mg PO daily, with a current LDL cholesterol of 1.8 mmol/L, meeting the target of less than 2.0 mmol/L. No changes are required to his lipid-lowering therapy, and I have encouraged him to engage in low-impact aerobic exercise, such as aquatic therapy or stationary cycling, for 30 minutes five days per week as his symptoms allow.

5. Follow-up and monitoring: I have provided Mr. Pendelton with a laboratory requisition to check his electrolytes, urea, and creatinine in two weeks to monitor for renal function changes or electrolyte derangements following the initiation of furosemide and empagliflozin, with a copy of the results directed to your office. I have arranged to see him again in the Internal Medicine clinic in eight weeks with a repeat hemoglobin A1C and NT-proBNP prior to the visit.

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Internal Medicine