CHIEF COMPLAINT: Shortness of breath.
HISTORY OF PRESENT ILLNESS: The patient is a pleasant (XX)-year-old woman with a history of primary lateral sclerosis as well as renal insufficiency. She has noticed increasing shortness of breath with activity for the last year. She said that walking is more difficult due to her neuromuscular weakness from her primary lateral sclerosis. She has been having more difficulty with balance. She has no other associated symptoms such as nausea, vomiting, palpitation, diaphoresis, syncope, or wheezing. She has an occasional nonproductive cough. She has never had hemoptysis. She has rare episodes of wheezing. She has no prior history of asthma and has never been treated with metered dose inhalers. She has had no PND, orthopnea, but does have some lower extremity edema. She does not wake up short of breath or gasping for breath at night. She has no history of gastroesophageal reflux. She denies any episodes of aspiration. She does have sinus congestion and occasional postnasal drip.
PAST MEDICAL HISTORY: Recurrent gout, chronic renal insufficiency with creatinine of 2.2, primary lateral sclerosis, congenital Jaccoud arthropathy, peripheral vascular disease, hyperlipidemia, hypertension, bilateral cataracts, uterine cancer status post hysterectomy, history of stroke, osteopenia.
CURRENT MEDICATIONS: Zetia, Tricor, atenolol, diazepam, amlodipine, hydrochlorothiazide, coenzyme Q10, folic acid, vitamin B12, vitamin D, aspirin, Flonase and allopurinol.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: The patient quit smoking 25 years ago, prior to that a 60-pack-year history. No alcoholic drinks. No history of tuberculosis. No industrial exposures.
FAMILY HISTORY: Sister with coronary artery disease.
REVIEW OF SYSTEMS: No fevers or chills. Her weight is unstable. She does have weakness due to her primary lateral sclerosis, but it has not progressed over the last year. All other systems reviewed and were negative.
PHYSICAL EXAMINATION: The patient is in no acute distress. Height 5 feet 6 inches, weight 128, blood pressure 128/78, pulse 72, room air oxygen saturation 98%. Head and neck exam shows no sinus tenderness. Pupils are equal, round and reactive. Oropharynx is clear. Her neck was supple without adenopathy or jugular venous distention. Trachea midline. No thyromegaly. Her lungs were clear to auscultation and percussion. Cardiovascular exam shows regular rate and rhythm, S1, S2, without murmurs, rubs or gallops. Abdomen shows normal bowel sounds, soft, nontender, without organomegaly or masses. Extremities show no clubbing, cyanosis or edema. On neurologic exam, she has dysarthria with her speech.
LABORATORY AND DIAGNOSTIC DATA: Chest x-ray, lateral and PA view, is clear. Spirometry suggests a moderate restrictive ventilatory defect with a reduced diffusion capacity, normal pulse oximetry. Sodium 134, potassium 4.8, chloride 98, bicarbonate 26, BUN 52, creatinine 2.2. She had a nuclear medicine cardiac test, which did not show any ischemic changes.
IMPRESSION AND PLAN: The patient is a pleasant (XX)-year-old woman with a history of primary lateral sclerosis and renal insufficiency, who has had increasing shortness of breath over the last year. Her pulmonary function tests are consistent with restrictive lung disease with reduced diffusion capacity, which could suggest interstitial lung disease. However, her chest x-ray is clear and her pulmonary exam is normal. Other possibilities would include neuromuscular weakness. Would like to check lung volumes as well as maximal inspiratory and expiratory pressures. It may also be reasonable to consider a cardiac echocardiogram looking for pulmonary hypertension. Part of her dyspnea may be related to increasing work of breathing in the setting of her neuromuscular weakness associated with the primary lateral sclerosis. Would like to see her in 3 to 4 weeks for followup after pulmonary function tests.
