Received Sep 15, 2025
| Type | Name | Manufacturer | Dose | Lot | Route / Site |
|---|---|---|---|---|---|
| COVID19 | COVID19 (COVID19 (MODERNA)) | MODERNA | 4 | — | SYR / RA |
Acute congestive heart failure (HCC) (HCC) POA: Unknown . New Onset Nonischemic Dilated cardiomyopathy with LVEF 30-35%. . Newly diagnosed acute decompensated congestive heart failure with reduced EF exacerbation resolved.
Subjective Patient ID: Patient is a 54 y.o. male. Chief Complaint Patient presents with ? Shortness of Breath Shortness of Breath This is a chronic problem. The current episode started more than 1 year ago. The problem occurs every few minutes. The problem has been waxing and waning. The average episode lasts 20 seconds. Associated symptoms include neck pain, orthopnea, PND, rhinorrhea and sputum production. Pertinent negatives include no abdominal pain, chest pain, ear pain, fever, headaches, leg swelling, rash, sore throat, vomiting or wheezing. The symptoms are aggravated by exercise, any activity, weather changes, eating and lying flat. Review of Systems Constitutional: Positive for fatigue. Negative for appetite change, chills, fever and unexpected weight change. HENT: Positive for congestion and rhinorrhea. Negative for ear pain, hearing loss, sinus pain, sore throat, tinnitus and voice change. Eyes: Positive for visual disturbance (keratoconus- sees ophthalmology). Negative for pain, discharge and redness. Respiratory: Positive for apnea (on c-pap), cough (12/2021 rx with azithromycin and 1/2022 rx with cefuroxime), sputum production and shortness of breath. Negative for wheezing. Cardiovascular: Positive for orthopnea and PND. Negative for chest pain, palpitations and leg swelling. Htn with stable Bps- 130s/80s Gastrointestinal: Negative for abdominal pain, blood in stool, constipation, diarrhea, nausea and vomiting. Colon polyp- benign- due 8/2021 Endocrine: Negative for polyuria. Genitourinary: Positive for flank pain and frequency (sees urology). Negative for dysuria, hematuria, penile discharge, testicular pain and urgency. Musculoskeletal: Positive for myalgias and neck pain. Negative for arthralgias and back pain. Skin: Negative for rash. Allergic/Immunologic: Negative for immunocompromised state. Neurological: Negative for dizziness, seizures, syncope, light-headedness and headaches. Hematological: Negative for adenopathy. Psychiatric/Behavioral: Negative for dysphoric mood, sleep disturbance and suicidal ideas. The patient is not nervous/anxious. Psychiatrist managing for ADD
Cough Obstructive sleep apnea on CPAP Other fatigue Type 2 diabetes mellitus with stage 3a chronic kidney disease, without longterm current use of insulin Hypertension, benign Mixed hyperlipidemia (HCC)
aliskiren 150 mg tablet Commonly known as: TEKTURNA amlodipine-atorvastatin 5-20 mg tablet Commonly known as: CADUET * amphetamine-dextroamphetamine 30 mg tablet Commonly known as: ADDERALL * amphetamine-dextroamphetamine 20 mg tablet Commo
None
EKG: Encounter Date: 09/16/22 ECG 12 lead Narrative og Test Date: 2022-09-16 Pat Name: Department: EAS042ED Patient ID: Room: B22 (STAT) Gender: Male Technician: DOB: Requested By: Order Number: 276642538 Reading MD: Measurements Intervals Axis Rate: 95 P: 57 PR: 167 QRS: 120 QRSD: 94 T: 5 QT: 375 QTc: 428 Interpretive Statements SINUS RHYTHM POSSIBLE RIGHT ATRIAL ENLARGEMENT [0.25mV P-WAVE] POSSIBLE RIGHT VENTRICULAR HYPERTROPHY [SOME/ALL OF: PROMINENT R IN V1, LATE TRANSITION, RAD, RAE, SSS] SEPTAL MYOCARDIAL INFARCTION , PROBABLY OLD [40+ ms Q WAVE IN V1/V2] No previous ECG available for comparison ECHOCARDIOGRAM: Summary: 1. Left ventricle: The cavity size is mildly dilated. Wall thickness is normal. Systolic function is moderately reduced. The estimated ejection fraction is 30-35%. There is moderate diffuse hypokinesis. Grade II diastolic dysfunction. Doppler parameters are consistent with elevated mean left atrial filling pressure. 2. Left atrium: The atrium is moderately dilated. 3. Mitral valve: There is moderate regurgitation. 4. Aortic root: The aortic root is normal-sized. 5. Right ventricle: The cavity size is normal. Systolic function is normal. 6. Right atrium: The atrium is normal in size. 7. Tricuspid valve: There is mild regurgitation. Estimated RVSP 45 mmHg. 8. Inferior vena cava: The IVC is dilated. 9. Pericardium, extracardiac: There is no pericardial effusion. Cardiac Catherization 9/21/22 - Cardiology recommended for patient to undergo left heart catheterization which was completed yesterday and revealed no significant coronary artery disease and marked elevated lvedp at 32 mmhg; Catheterization results were discussed with patient by cardiologist now found to have a nonischemic cardiomyopathy. Implantable cardioverter defibrillator insertion 1/13/22 GeneDx Genetic Test for Cardiomyopathy 4/11/23 - This test did not fi nd any disease causing genetic changes (variants) linked to cardiomyopathy in the genes tested. Everygene Genetic Test for Cardiomyopathy 7/28/25 - This test did not find any disease causing genetic changes (variants) linked to cardiomyopathy in the genes tested. No Medical History of: Chagas disease, Pregnancy, Alcohol use disorder, Non-alcoholic toxic insults include administration of certain chemotherapeutic agents, in particular doxorubicin (Adriamycin), and cobalt, Thyroid disease, Inflammatory diseases such as sarcoidosis and connective tissue diseases , Tachycardia-induced cardiomyopathy, Muscular dystrophy, Tuberculosis, Autoimmune Disease, Thiamine deficiency