REASON FOR CONSULTATION: This patient has been sent to me by Dr. (XX) to be evaluated as a potential candidate for cardiac transplant.
HISTORY OF PRESENT ILLNESS: The patient is (XX). He has sort of a mixed picture. He had a myocardial infarction with stents in (XXXX). However, now is felt to have LV dysfunction out of proportion to his coronary artery disease, though at least from what we can put together, he has not had a coronary arteriogram since his myocardial infarction in (XXXX). He has had 3 hospitalizations for heart failure in the past year. His ejection fraction is said to be around 10%. Despite medical therapy, he has a recurrent left arm numbness, which I suppose could be angina. He does not take nitro. He has nightly paroxysmal nocturnal dyspnea. He cannot walk more than a block. He has not had fevers or chills. He had an ICD discharge but apparently it was last year. He has lost 10 pounds.
PAST MEDICAL HISTORY: There is a history of chest pain, which may be angina, dysphagia, hemoptysis, and a nodule. History of hyperlipidemia, hypertension, he has an AICD, low-grade diabetes, some mitral insufficiency. The patient has a Biotronik BiV.
SOCIAL HISTORY: The patient has been married (XX) years. He has 2 sons, lives locally, used to work in the maintenance world. Has been disabled since (XXXX). He does not smoke, does not drink alcohol. There is no history for recreational drug use.
FAMILY HISTORY: Mother, aged 72, died of heart failure. Father, aged 78, died of old age. He had 2 brothers, who died, both secondary to coronary artery disease.
ALLERGIES: The patient has no allergies.
CURRENT MEDICINES:
1. Aspirin 81 mg a day.
2. Coreg 6.25 p.o. b.i.d.
3. Dig 0.25 mg daily.
4. Lasix 40.
5. Simvastatin 40.
6. Aldactone 25.
7. Diovan 40. He had an ACE cough, which led to the Diovan.
The patient got a pneumonia shot in (XXXX), influenza shot also in (XXXX).
REVIEW OF SYSTEMS: In terms of his 14-point review of systems, he has lost 10 pounds. He has upper dentures and without any recent dental issues. Bothered by dizziness at times. Numbness in the left arm and neck, which I suppose could be an anginal equivalent. Cough on lisinopril. He has not had a colonoscopy. Did have upper endoscopy in January for bleeding, which was negative. Otherwise, his 14-point review of systems is negative and noncontributory.
PHYSICAL EXAMINATION:
GENERAL: He is a thin male, in no acute distress.
VITAL SIGNS: He weighs (XXX) pounds. He is 5 feet 11 inches. Blood pressure is 108/74. Pulse is 86.
SKIN: Unremarkable. There is no palpable adenopathy.
Cranial nerves II through XII were physiologic.
NECK: Jugular venous pressure is flat with negative hepatojugular reflux. Carotids are normal.
HEENT: Pupils are equal, round, react to light and accommodation.
LUNGS: He has sort of these coarse breath sounds at the bases, almost sounds like pleural rubs, without real rales or
wheezes.
HEART: There is a regular rhythm. Normal first and second sound, probably mitral murmur with filling sound.
ABDOMEN: Soft. There is no organomegaly. We cannot feel liver or spleen. Bowel sounds are active. We cannot feel
the spleen, abdominal aorta.
EXTREMITIES: Femoral distal pulses are full. There is no edema, cyanosis or clubbing.
NEUROLOGIC: Grossly intact.
LABORATORY DATA: We really do not have a lot of laboratory data. We do know that his ejection fraction is said to be 10. I guess the endoscopy was because of chest pain, so I am concerned this might be GI in origin. Of concern, echo suggests a PA pressure of almost 100. There is moderate to severe mitral insufficiency. There is mild aortic insufficiency, severe tricuspid insufficiency.
IMPRESSION AND PLAN: This patient, I think, at first glance, certainly looks like a reasonable candidate for cardiac transplant. My only concern is his PA pressure. Obviously, if we have refractory pulmonary hypertension, we may have to think about maybe an LVAD bridge to transplant try and get those pressures down. Today, current plan will be for him to be admitted for transplant evaluation on Thursday, so they can make arrangements for this. Risks, alternatives, and benefits of cardiac catheterization were discussed with him and his family. Plan will be probably to admit Thursday for combined cath and ongoing transplant evaluation.
