Comprehensive Cardiac Case Study

This is not a real patient chart. The names and data have been created.

Patient Chart

Patient Name: Sarah Elizabeth Thompson
Date of Birth: 07/15/1963
Age: 61
Gender: Female
Medical Record Number: 20250311
Date of Admission: 03/11/2025
Primary Care Provider: Dr. John Peterson

Chief Complaint (CC)

"I’ve been having shortness of breath, chest pain, and swelling in my legs for the past week. It’s getting worse every day."

History of Present Illness (HPI)

Sarah Thompson is a 61-year-old female with a history of hypertension, hyperlipidemia, and a myocardial infarction 4 years ago. She presents with a 1-week history of increasing shortness of breath, particularly with exertion, and intermittent chest discomfort. The chest pain is described as a pressure-like sensation, radiating to the left arm, and occurring during physical activity. It improves with rest but has been progressively worsening over the past few days.

In addition, the patient has noticed increasing bilateral leg swelling, which worsens by the evening. She also reports feeling fatigued and unable to perform her usual activities. She denies any recent trauma or changes in diet or medications.

She has been on her regular medications, including a beta-blocker and statin, but has not been following her dietary recommendations for salt intake. Her last follow-up appointment was 6 months ago, and her blood pressure was poorly controlled at that time.

Past Medical History (PMH)

  • Hypertension – diagnosed 20 years ago, poorly controlled, currently on Lisinopril
  • Hyperlipidemia – diagnosed 15 years ago, controlled with Atorvastatin
  • Myocardial Infarction (MI) – 4 years ago, treated with angioplasty and stent placement
  • Congestive Heart Failure (CHF) – diagnosed post-MI, treated with ACE inhibitors and diuretics
  • Type 2 Diabetes Mellitus – diagnosed 5 years ago, controlled with Metformin

Surgeries & Procedures

  • Angioplasty with stent placement for myocardial infarction (4 years ago)
  • Cholecystectomy (10 years ago)

Allergies

  • Penicillin – Rash

Medications

  • Lisinopril 20 mg daily
  • Atorvastatin 40 mg nightly
  • Metformin 500 mg twice daily
  • Furosemide 40 mg daily
  • Aspirin 81 mg daily
  • Nitroglycerin as needed for chest pain

Family History (FH)

  • Father: Deceased, 75, with a history of hypertension and heart disease
  • Mother: Alive, 85, with a history of hypertension and stroke
  • Brother: Alive, 58, with type 2 diabetes and hypertension

Social History (SH)

  • Smoking: Quit 10 years ago (15 pack-years)
  • Alcohol: Occasional drinker (1-2 drinks per week)
  • Drug Use: Denies illicit drug use
  • Occupation: Retired teacher
  • Living Situation: Lives with husband, independent in activities of daily living

Review of Systems (ROS)

  • General: Fatigue, weight gain (due to edema), no fever
  • Cardiovascular: Shortness of breath, chest pain, bilateral leg swelling, palpitations
  • Respiratory: No cough or wheezing, shortness of breath on exertion
  • Gastrointestinal: No nausea, vomiting, or abdominal pain
  • Neurological: No headaches, dizziness, or syncope
  • Musculoskeletal: No joint pain or swelling

Physical Assessment Findings

Vital Signs:

  • Temperature: 98.6°F (37.0°C)
  • Heart Rate: 92 bpm, regular
  • Respiratory Rate: 20 breaths/min
  • Blood Pressure: 160/95 mmHg
  • Oxygen Saturation: 92% on room air
  • Height: 5'8"
  • Weight: 218 lbs.

General Appearance: Overweight female, alert, in moderate distress due to dyspnea
Cardiovascular: Regular rate and rhythm, faint S3 heart sound, bilateral lower extremity edema (2+ pitting), no jugular venous distention
Respiratory: Mild crackles in the bases of both lungs, no wheezing
Abdomen: Soft, non-tender, no hepatomegaly or ascites
Neurological: Alert and oriented, no focal deficits

Laboratory Results

Basic Metabolic Panel (BMP)

Test Result Reference Range
Sodium (Na) 138 mEq/L 135-145 mEq/L
Potassium (K) 4.2 mEq/L 3.5-5.1 mEq/L
Chloride (Cl) 102 mEq/L 98-107 mEq/L
Bicarbonate (HCO₃) 24 mEq/L 22-28 mEq/L
Blood Urea Nitrogen (BUN) 22 mg/dL 7-20 mg/dL
Creatinine (Cr) 1.1 mg/dL 0.6-1.2 mg/dL
Glucose (fasting) 110 mg/dL 70-99 mg/dL

Complete Blood Count (CBC)

Test Result Reference Range
White Blood Cell Count (WBC) 7.2 x10³/µL 4.0-11.0 x10³/µL
Hemoglobin (Hgb) 13.5 g/dL 12.0-16.0 g/dL
Hematocrit (Hct) 40% 36-46%
Platelets (Plt) 240 x10³/µL 150-450 x10³/µL

Liver Function Tests (LFTs)

Test Result Reference Range
Alanine Aminotransferase (ALT) 30 U/L 10-40 U/L
Aspartate Aminotransferase (AST) 34 U/L 10-40 U/L
Alkaline Phosphatase (ALP) 110 U/L 45-115 U/L
Bilirubin, Total 0.7 mg/dL 0.1-1.2 mg/dL

Arterial Blood Gas (ABG)

Test Result Reference Range
pH 7.37 7.35-7.45
PaO₂ 75 mmHg 75-100 mmHg
PaCO₂ 41 mmHg 35-45 mmHg
HCO₃ 24 mEq/L 22-28 mEq/L
Oxygen Saturation (SaO₂) 91% 95-100%

Electrocardiogram (ECG)

Findings:

  • Sinus rhythm, Q waves in leads II, III, and aVF, indicative of previous myocardial infarction.
  • Mild ST-segment depression in leads V2-V4, suggestive of ischemia.

Echocardiogram

Findings:

  • Left ventricular ejection fraction (LVEF) of 35%, indicating reduced cardiac function.
  • Mild mitral regurgitation.
  • Mild pericardial effusion.