Identifying Data:
Full Name: Mr. A
Address: Forest Hill, NY
Date of Birth: April 24, 1968
Date & Time: June 2nd, 2020
Location: Queens Line Medical Center, Ozone Park, NY
Religion: Catholic
Source of Information: Self
Source of Referral: Self
Mode of Transport: Son dropped him off
Chief Complaint: “I have a cough that won’t let me sleep at night” x 3 days.
HPI:
Mr. A is a 52-year-old male with a PMH of D2M, HTN/HLD and BPH is here due to complaints of cough. Patient states the cough started 3 days ago when he was trying to go to sleep. Patient describes the cough as non-productive and dry. Mr. A states that every-time he coughs he also experiences mild chest pain that usually last for only 2 seconds and when asked for the location of the pain, he points in the middle of his chest and states its a sharp pain which does not radiate anywhere. Pt states the cough is constant throughout the day and it becomes more frequent at nighttime. He has tried melatonin to help him sleep at night but has not worked. Chest pain does not bother him as much as the cough and states the chest pain is only a 2/10 on the severity scale. Patient states that he came in today for a checkup because he gets very little sleep at night due to the cough and feels tired throughout the day. Mr. A denies nausea, vomiting, wheezing, headaches, rhinorrhea, hematemesis, fever, chills, SOB, palpitations, irregular heartbeat, syncope, leg edema and dyspnea on exertion
Past Medical History:
Present illnesses – Type 2 DM x 4 years; BPH x 2 years; HTN/HLD x 4 years
Past medical illnesses – Appendicitis 28 years ago (at 24 years old)
Hospitalizations: Appendectomy at age 24, done in California, does not remember the name of the surgeon. No complications.
Immunizations- Up to date, except yearly influenze shot.
Screening tests and results- Colonoscopy done in 2018, benign.
Past Surgical History:
Appendectomy at age 24, done in California, does not remember the name of the surgeon. No complications.
Medications:
Flomax 0.4 mg PO at bedtime for BPH, last dose was last night.
Atorvastatin, 20 mg PO QHS for HLD, last dose last night before bedtime.
Metformin HCL, PO, 500mg Monday/Wednesday/Friday for DM2, last dose this morning
Lisinopril PO, daily 5mg for HTN, last dose was this morning.
Multivitamins CAP/TAB 2 tablets PO daily supplement for overall health
Allergies:
Denies drug, environmental or food allergies.
Family History:
Denies family history of cardiovascular diseases, colon cancer, strokes.
Social History:
Admits to alcohol consumption almost every weekend about 2 beers a day when he meets up with his friends.
Denies tobacco and illicit drug use.
Travel- Has not recently traveled anywhere.
Sexual Hx- Not sexually active. No past history of STD’s, HIV or any other sexually transmitted diseases.
Review of Systems:
General: denies loss of appetite, fever, recent weight loss or gain, generalized weakness/fatigue, or night sweats.
Mouth/throat –Denies bleeding gums, sore tongue, sore throat, mouth ulcers, voice changes. Last dental exam 2019.
Neck– Denies localized swelling/lumps or stiffness/decreased range of motion.
Gastrointestinal system – Pt states he feels burning sensation in his chest and throat only when drinking alcohol or eating spicy wings. This has been going on for 2 weeks. Patient has regular bowel movements daily. Denies vomiting, nausea, dysphagia, unusual flatulence, abdominal pain, diarrhea, jaundice, hemorrhoids, constipation, rectal bleeding, or blood in stool.
Pulmonary system – Patient states he has cough that’s been going on for the past 3 days and can’t sleep at night. Denies, dyspnea, dyspnea on exertion, wheezing, hemoptysis, cyanosis, orthopnea, or paroxysmal nocturnal dyspnea (PND).
Cardiovascular system – Patient states he has mild chest pain every time he coughs. Patient denies irregular heartbeat, edema, syncope or known heart murmur.
Physical exam:
General: Pt is alert and oriented x3, neatly groomed, no apparent distress and responsive to verbal commands.
Vital Signs: BP: R L
Seated 135/85 130/80
Supine 125/85 130/80
R: 17/min unlabored P: 87, regular
T: 97.6 degrees F (oral) O2 Sat: 98% Room air
Height 5 feet and 6 inches Weight 180 lbs. BMI: 29.0 (overweight)
Neck – Trachea midline. No masses; lesions; scars; pulsations noted. Supple; non-tender to palpation. FROM; no stridor noted. 2+ Carotid pulses, no thrills; bruits noted bilaterally, no palpable adenopathy noted.
Thorax & Lungs:
Chest– Slight pain when palpating in the middle of the chest. Symmetrical, no deformities, no evidence of trauma. Respirations unlabored, no paradoxical respirations or use of accessory muscles noted. Lat to AP 2:1, non-tender to palpations.
Lungs– Clear to auscultation and percussion bilaterally. Chest expansions and diaphragmatic excursions symmetrical. Tactile fremitus symmetric throughout. No adventitious sounds.
Heart: No tenderness to palpation. JVP is 2.5 cm above the sternal angle with the head of the bed at 30°. PMI in 5th ICS in mid-clavicular line. Carotid pulses are 2+ bilaterally without bruits. Regular rate and rhythm (RRR); S1 and S2 are normal. There are no murmurs, S3, S4, splitting of heart sounds, friction rubs or other extra sounds.
Abdomen: No hernias noted. Flat / symmetrical / no evidence of scars, striae, caput medusae or abnormal pulsations. BS present in all 4 quadrants. No bruits noted over aortic/renal/iliac/femoral arteries. Tympany to percussion throughout. Non-tender to percussion or to light/deep palpation. No evidence of organomegaly. No masses noted. No evidence of guarding or rebound tenderness. No CVAT noted bilaterally.
Assessment:
Mr. A is a 52-year-old male with a PMH of D2M, HTN/HLD and BPH is here due to complaints of cough and mild chest pain that has been going on for 3 days. Patient also reports burning sensation in his chest and throat only when drinking alcohol or eating spicy food. On exam, pt has stable vital signs and benign physical exam with the exception of some mild chest pain when palpating.
Differential Diagnosis:
1) Most likely GERD: Patient presents with cough that gets worse at nighttime when he lays down to go to sleep. Later on, during ROS patient also states that he experiences heartburn (pyrosis) when drinking alcohol and eating spicy food which further points to a GERD diagnosis. Also, with no signs of fever, chills, N/V, rhinorrhea, or nasal obstruction points away from a bacterial infection or viral infection. When it comes the chest pain that the patient is complaining about, I think that is most likely due to the high frequency of coughs our patient is experiencing and the pain on palpation further backs that up. The intercostal muscles may be sore due to constant coughing.
2) Likely due to medication. Patient has a history of HTN and the only medication he is currently taking is Lisinopril. Lisinopril is an ACEi and known to cause cough in patients as it increases levels of bradykinin.
3) Myocardial infarction/ Stable Angina: Although unlikely, given the patients age and history of HTN and Hyperlipidemia, its important that we rule out MI and do further testing to see if its stable angina (stress testing).
4) COVID-19
Plan:
1) Order CBC, CMP, Hemoglobin A1C.
2) Refer to GI for a 24hr ambulatory pH monitoring while at the same time start patient on omeprazole, 20 mg orally once a day for 4 weeks and see if he gets any better.
3) Refer to Cardio to perform stress testing and rule in/out angina.
4) Discontinue Lisinopril and instead place patient on an ARB like Losartan, 50 mg orally once a day as ARBs are less likely to cause cough.
5) Continue with Flomax 0.4 mg PO at bedtime for BPH.
6) Continue with Atorvastatin, 20 mg PO QHS for HLD.
7) Continue with Metformin HCL, PO, 500mg Monday/Wednesday/Friday for DM2.
8) Lifestyle modifications: suggest patient to sleep with his head elevated up to 6 inches with a pillow or 2. Avoid eating late at night, avoid eating spicy food, fatty food, chocolate, peppermint, or caffeinated products, and reduce alcohol intake.
9) Also refer patient to physical therapy to encourage working out as it can help reduce GERD symptoms. (BMI of 29).
10) Advise patient to follow up in 4 weeks after he finishes omeprazole.
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