Post MI, new diagnosis of diabetes
Johnny is a 56-year-old man presenting for a post-hospitalization primary care office visit. He was recently hospitalized with an inferior ST-segment elevation myocardial infarction (MI) treated by percutaneous coronary intervention and drug-eluting stenting to the right coronary artery. He was hospitalized for two days, during which time he was noted to have high blood sugar and hemoglobin A1c consistent with type 2 diabetes mellitus (T2DM). An echocardiogram during hospitalization revealed a normal left ventricular ejection fraction (60 percent).
He was discharged to home with new medications and a prescription for cardiac rehab. He is employed as a construction worker, is eager to get back to work for financial reasons and wanted your OK following discharge. He reports that he has had palpitations and some episodes of shortness of breath starting about a month after discharge.
He was discharged on lisinopril 20 mg daily, metoprolol titrate 100 mg bid, atorvastatin 40 mg daily, ASA 81 mg daily, clopidogrel 75mg po daily.
Past Medical History: Hyperlipidemia
Medications: He was prescribed atorvastatin in 2016 but he said he got muscle aches and stopped taking it. He had not started these new meds yet as he wanted to check with you first.
Social History: The patient works in construction, he self-pays for care (no insurance) and he is worried about his bills from the hospital. He is married and has two children and is worried about the lost work with cardiac rehab.
Patient doesn’t use tobacco products and has one to two beers per week, usually on Fridays. He does not read food labels or pay much attention to what he eats, leaving menu decisions to his wife. He doesn’t consume many fresh fruits, vegetables, whole grains or fish. The family usually has beef for dinner; chicken once in a while and fish infrequently. He has no regular activity or exercise program because he assumes he gets more than enough exercise at work.
Exam: BMI 34, 5 ft 6 inches, 210 lbs, blood pressure 142/88, heart rate 84, respiratory rate 16, pain 0/10, 5 ft 6 inches, 210 lbs
General: Obese, Acanthosis on neck, Truncal obesity
Heart: RRR no murmurs, rubs or gallops, PMI not displaced.
Vascular: Carotids normal upstroke no bruits posterior tibial and pedal pulses normal
Resp: CTA A and P
Labs: if we need them
eGFR 140ml /min
HbA1c = 8.4%
Lipids: total cholesterol 246, HDL-C 24, TG 220, LDL-C 178