Internal Medicine New Patient Assessment

2023-10-25

Reason for Referral

Arthur Pendelton was referred for assessment of poorly controlled hypertension and progressive exertional dyspnoea over the past three months.

Patient Details

Patient Name: Arthur Pendelton

Patient Age: 64 years

History of Presenting Illness

Arthur Pendelton presents with a three-month history of progressive shortness of breath on exertion, now occurring after walking two city blocks on level ground. He also notes intermittent bilateral ankle swelling by the end of the day. Home blood pressure readings have consistently averaged 165/95 mmHg despite adherence to his current regimen. He denies orthopnoea, paroxysmal nocturnal dyspnoea, chest pain, palpitations, or syncope.

Social History

Arthur Pendelton works as a high school history teacher and has extended health insurance coverage through his employer. He is a former smoker with a 20 pack-year history, having quit 10 years ago. He consumes approximately four standard alcoholic drinks per week.

Past Medical History

Arthur Pendelton has a history of essential hypertension diagnosed eight years ago, dyslipidaemia, and obesity. He underwent a laparoscopic cholecystectomy in 2015 without complications.

Medications

Arthur Pendelton currently takes perindopril (Coversyl®) 8 mg PO daily and rosuvastatin (Crestor®) 10 mg PO daily. He reports good compliance and no medication allergies.

Family History

Arthur Pendelton's father had a myocardial infarction at age 62, and his mother had hypertension and type 2 diabetes mellitus.

Physical Examination

BP: 162/94 mmHg HR: 76 bpm RR: 16 breaths/min Temp: 36.7 °C SpO2: 97 % on room air Weight: 98 kg

General: Arthur Pendelton is alert, oriented, and in no acute distress. Cardiovascular: Normal S1 and S2 with no murmurs, rubs, or gallops, JVP is 2 cm above the sternal angle, and there is trace pitting oedema at the ankles bilaterally. Respiratory: Chest is clear to auscultation bilaterally with no wheezes or crackles. Abdomen: Abdomen is soft, non-tender, and non-distended with no hepatosplenomegaly.

Investigations

Laboratory Investigations

2023-10-15: Haemoglobin 145 g/L 2023-10-15: Creatinine 92 µmol/L, eGFR 74 mL/min/1.73 m² 2023-10-15: Potassium 4.2 mmol/L 2023-10-15: Sodium 139 mmol/L 2023-10-15: HbA1c 5.8 % 2023-10-15: LDL-C 2.1 mmol/L 2023-10-15: NT-proBNP 185 pg/mL

Stress Test Findings

Date: 2023-10-18 Resting ECG: Normal sinus rhythm with left ventricular hypertrophy criteria. Resting HR: 74 bpm Peak HR: 148 bpm (95 % of maximum predicted) Total Duration: 8 minutes 30 seconds on Bruce protocol Achieved METs: 9.2 METs ST-segment changes: No significant ST-segment depression or elevation. Conclusion: The stress test was described as normal with no inducible ischaemia, though a hypertensive blood pressure response was noted at peak exercise (210/105 mmHg).

Summary

Arthur Pendelton presents with uncontrolled hypertension and mild exertional dyspnoea, likely secondary to hypertensive heart disease and diastolic dysfunction rather than coronary ischaemia, given his normal exercise stress test. We discussed the importance of stricter blood pressure control, dietary sodium restriction, and regular aerobic exercise. A transthoracic echocardiogram has been arranged to evaluate left ventricular function and structure, and he will follow up in six weeks.

Plan

1. Add indapamide (Lozide®) 1.25 mg PO daily to the current regimen for improved blood pressure and mild volume control.
2. Continue perindopril (Coversyl®) 8 mg PO daily and rosuvastatin (Crestor®) 10 mg PO daily.
3. Order a transthoracic echocardiogram to assess left ventricular systolic and diastolic function.
4. Check repeat renal function and electrolytes (sodium, potassium, creatinine) in two weeks following the initiation of indapamide.
5. Advise Arthur Pendelton to restrict dietary sodium intake to less than 2,000 mg daily and maintain a log of home blood pressure readings.
6. Arrange a follow-up appointment in the clinic in six weeks to review echocardiogram results and blood pressure log.