General Internal Medicine Follow-up

Subjective:
Chief Complaint:
Shortness of breath, palpitations and left ankle swelling.

History of Present Illness:
Helen Carter is an 85-year-old female with a history of multiple myeloma, coronary artery disease, and pulmonary hypertension, among other conditions, who is currently undergoing chemotherapy. She reports feeling under the weather for the past few days, which she attributes to the effects of her chemotherapy rather than an infectious cause. She has experienced palpitations and swelling in her left ankle, which she notes has occurred previously. She also reports a cough but denies any flu or cold symptoms. There have been no changes to her medications apart from adjustments to her chemotherapy regimen, which was reduced due to prior episodes of diarrhea. She denies any bleeding. Her last medication adjustment was in October, and she remains compliant with her prescribed regimen.

The Review of Systems:
Cardiovascular – She reports palpitations and swelling in her left ankle, which she notes has occurred previously. She denies chest pain, dizziness, or any other cardiovascular symptoms.
Respiratory – She reports a cough but denies shortness of breath, wheezing, or any flu or cold symptoms.

Current Medications:
She is currently taking atorvastatin 80 mg in the evening, bisoprolol 2.5 mg daily, clopidogrel 75 mg daily, aspirin 81 mg daily, ascorbic acid 1 tablet daily, bimatoprost ophthalmic 0.01% solution 1 drop in both eyes in the evening, calcium carbonate 500 mg three times daily, pantoprazole 40 mg daily, ramipril 10 mg daily, timolol ophthalmic 0.5% solution 1 drop in both eyes twice daily, trazodone 25 mg in the evening, and valacyclovir 500 mg daily. Her chemotherapy regimen, which includes lenalidomide, dexamethasone, and bortezomib, has been reduced due to prior episodes of diarrhea. There have been no other changes to her medications since October.

Allergies:
She has a known allergy to caffeine, which causes tinnitus, and alendronic acid, which causes muscle and joint pain. No new allergies have been reported.

Past Medical History:
Helen Carter has a complex medical history that includes multiple chronic and significant conditions. She has a diagnosis of multiple myeloma, specifically lambda light chain disease, which was confirmed through a bone marrow aspiration and biopsy in May 2024, revealing plasma cells constituting 50% of marrow cellularity with lambda light chain positivity. She has undergone one cycle of chemotherapy with a regimen including lenalidomide, dexamethasone, and bortezomib, though this was temporarily reduced due to adverse effects such as diarrhea. Additionally, she has a history of coronary artery disease, with a significant event of an anterior ST-elevation myocardial infarction (STEMI) on October 4, 2024, which necessitated thrombolysis with TNK and subsequent percutaneous coronary intervention (PCI) with the placement of a drug-eluting stent (DES) in the mid-left anterior descending artery (LAD). Her left ventricular ejection fraction (LVEF) was noted to be 49% at the time of admission. She is currently on dual antiplatelet therapy with clopidogrel and aspirin, with a recommendation to continue clopidogrel for at least one year, provided there are no bleeding complications. She also has a history of moderate to severe pulmonary hypertension, first identified on an echocardiogram in April 2016, with a pulmonary artery pressure of 66 mmHg, and confirmed through a right heart catheterization in August 2016. This condition is suspected to be secondary to underlying connective tissue disease, as she has a remote history of lupus, though she has been off immunosuppressive therapy since 2005. Her cardiovascular history is further complicated by long QT syndrome, though genetic testing for this condition was negative. She has a history of osteoporosis, with compression fractures at L4 and L5 noted in 2022, and a recent DEXA scan in January 2024 confirming severe osteoporosis with a lumbar spine T-score of -3.4 and a femoral neck T-score of -4.0. She is currently receiving denosumab injections every six months for this condition. Her musculoskeletal history also includes chronic pain stemming from a motor vehicle accident in the 1980s, which resulted in a spinous fracture of C6, as well as ongoing vertebral pain due to her compression fractures. She has a history of glaucoma, macular edema, and cataracts, for which she follows up with ophthalmology. Her psychiatric history includes longstanding depression. Additionally, she has a remote history of tuberculosis in the 1960s, which presented as submandibular lymphadenopathy and resulted in reticulonodular opacification in the right upper lobe and left lower lobe, attributed to latent TB with scarring. Her medication regimen is extensive and includes atorvastatin, bisoprolol, clopidogrel, aspirin, calcium carbonate, pantoprazole, ramipril, trazodone, valacyclovir, and ophthalmic solutions for glaucoma. She has documented allergies to caffeine, which causes tinnitus, and alendronic acid, which causes muscle and joint pain.

Past Surgical History:
Helen Carter has undergone several surgical procedures in the past. These include a cholecystectomy, appendectomy, and hysterectomy, though the exact dates of these procedures are not specified. She also underwent a skin biopsy in 1992, which was consistent with guttate psoriasis. She has had multiple endoscopic procedures, including an upper endoscopy in November 2012, which was histologically normal, and another in February 2014, which revealed a tubular adenoma without evidence of high-grade dysplasia. She underwent a coronary angiogram in August 2016, which showed mild coronary artery disease and led to the initiation of diltiazem for intermittent episodes of atypical chest pain and shortness of breath. Additionally, she had a colonoscopy in December 2018, which revealed diverticula but no other significant findings.

Family History:
She denies any family history of coronary artery disease, arrhythmias, or sudden cardiac death. However, she reports that her sister was diagnosed with breast cancer and her father had prostate cancer.

Social History:
Helen Carter is a retired nurse who worked for many years at a health center. She is a non-smoker and does not consume alcohol. She denies any use of recreational drugs or THC. There is no mention of her marital status or living situation in the transcript.

Objective:
Physical Examination:
General – Appears well, alert, no acute distress
Cardiovascular – Heart rate regular, S1S2 normal, no murmurs
Respiratory – Lungs clear to auscultation bilaterally, no wheezes or crackles

Investigations:
Recent investigations include a cardiac echocardiogram performed on October 6, 2024, which revealed a left ventricular ejection fraction (LVEF) of 49%, abnormal ventricular septal motion, global left ventricular hypokinesis, moderate diastolic dysfunction, eccentric left ventricular hypertrophy, normal right ventricular systolic function, and mildly elevated pulmonary artery systolic pressure (PASP) of 48 mmHg. The echocardiogram also noted a sclerotic trileaflet aortic valve with mild to moderate aortic regurgitation and mitral regurgitation. A prior echocardiogram on December 19, 2023, showed an LVEF of 40-45%, normal right ventricular function, aortic sclerosis with moderate regurgitation, mild mitral and tricuspid regurgitation, and moderate pulmonary hypertension with a PASP of 55 mmHg. A 24-hour Holter ECG conducted on January 20, 2024, demonstrated sinus rhythm throughout, with an average heart rate of 70 beats per minute, ranging from 53 to 125 beats per minute, and frequent ventricular ectopy, including ventricular triplets, but no significant ST changes. Laboratory investigations from October 17, 2024, revealed a white blood cell count of 2.6, hemoglobin of 86, mean corpuscular volume of 94.8, and platelets of 304. Renal panel results showed sodium of 141, potassium of 4.3, creatinine of 85, and an estimated glomerular filtration rate of 54. Comprehensive metabolic panel results included calcium of 2.38, albumin of 0.92, and bilirubin of 1.33. C-reactive protein was 1.16. Immunoglobulin studies from September 7, 2024, showed IgA of 0.47, IgG of 6.98, and IgM of 0.33. Beta-2 microglobulin was 2.7. Hepatitis B and C serologies were nonreactive. Protein electrophoresis from April 5, 2024, revealed a free lambda monoclonal light chain band in the beta-gamma region and a faint IgG lambda monoclonal protein band in the gamma region, with slight gamma suppression.

Assessment:
Problem:

1. [Problem 1]: Palpitations and left ankle swelling (729.5) – She reports experiencing palpitations and swelling in her left ankle, which she notes has occurred previously. These symptoms are concerning for potential cardiovascular or fluid retention issues, particularly given her history of coronary artery disease and pulmonary hypertension. An echocardiogram has been ordered to investigate further.
2. [Problem 2]: Cough (786.2) – She reports a cough but denies any flu or cold symptoms. This could be related to her underlying pulmonary hypertension or a side effect of her chemotherapy. Further evaluation is warranted.
3. [Problem 3]: Chemotherapy side effects (530.81) – She attributes her recent feeling of being under the weather to the effects of her chemotherapy. Her regimen has been adjusted due to prior episodes of diarrhea, and she remains compliant with her treatment plan.

Clinical Impression:
She is an 85-year-old female with a history of multiple myeloma, coronary artery disease, and pulmonary hypertension, among other conditions, who is currently undergoing chemotherapy. She reports feeling under the weather, which she attributes to the effects of her chemotherapy. She has experienced palpitations, left ankle swelling, and a cough, but denies any flu or cold symptoms. Her chemotherapy regimen has been adjusted to reduce side effects, and she remains compliant with her prescribed medications. An echocardiogram has been ordered to evaluate her shortness of breath and cough.

Plan:

• Orders and Referrals  
• An echocardiogram has been ordered to evaluate her shortness of breath and cough. No additional referrals are required at this time.  
• Treatments  
• No changes to her current medications or chemotherapy regimen are being made at this time.  
• Patient Education  
• She has been advised to monitor her symptoms and report any worsening or new symptoms, such as increased swelling, chest pain, or shortness of breath.  
• Follow Up  
• She will have an in-person follow-up appointment on April 18, 2025, at 11:00 AM to evaluate her symptoms and review the echocardiogram results.