DATE OF CONSULTATION: MM/DD/YYYY
REFERRING PHYSICIAN: John Doe, MD
CONSULTING PHYSICIAN: Jane Doe, MD
REASON FOR CONSULTATION: Surgical evaluation for coronary artery disease.
HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old female who has a known history of coronary artery disease. She underwent previous PTCA and stenting procedures in December and most recently in August. Since that time, she has been relatively stable with medical management. However, in the past several weeks, she started to notice some exertional dyspnea with chest pain.
For the most part, the pain subsides with rest. For this reason, she was re-evaluated with a cardiac catheterization. This demonstrated 3-vessel coronary artery disease with a 70% lesion to the right coronary artery; this was a proximal lesion. The left main had a 70% stenosis. The circumflex also had a 99% stenosis. Overall left ventricular function was mildly reduced with an ejection fraction of about 45%. The left ventriculogram did note some apical hypokinesis. In view of these findings, surgical consultation was requested and the patient was seen and evaluated by Dr. Doe.
PAST MEDICAL HISTORY:
1. Coronary artery disease as described above with previous PTCA and stenting procedures.
2. Dyslipidemia.
3. Hypertension.
4. Status post breast lumpectomy for cancer with followup radiation therapy to the chest.
ALLERGIES: None.
MEDICATIONS: Aspirin 81 mg daily, Plavix 75 mg daily, Altace 2.5 mg daily, metoprolol 50 mg b.i.d. and Lipitor 10 mg q.h.s.
SOCIAL HISTORY: She quit smoking approximately 8 months ago. Prior to that time, she had about a 35- to 40-pack-year history. She does not abuse alcohol.
FAMILY MEDICAL HISTORY: Mother died prematurely of breast cancer. Her father died prematurely of gastric carcinoma.
REVIEW OF SYSTEMS: There is no history of any CVAs, TIAs or seizures. No chronic headaches. No asthma, TB, hemoptysis or productive cough. There is no congenital heart abnormality or rheumatic fever history. She has no palpitations. She notes no nausea, vomiting, constipation, diarrhea, but immediately prior to admission, she did develop some diffuse abdominal discomfort. She says that since then, this has resolved. No diabetes or thyroid problem. There is no depression or psychiatric problems. There is no musculoskeletal disorders or history of gout. There are no hematologic problems or blood dyscrasias. No bleeding tendencies. Again, she had a history of breast cancer and underwent lumpectomy procedures for this with followup radiation therapy. She has been followed in the past 10 years and mammography shows no evidence of any recurrent problems. There is no recent fevers, malaise, changes in appetite or changes in weight.
PHYSICAL EXAMINATION: Her blood pressure is 120/70, pulse is 80. She is in a sinus rhythm on the EKG monitor. Respirations are 18 and unlabored. Temperature is 98.2 degrees Fahrenheit. She weighs 160 pounds, she is 5 feet 4 inches. In general, this was an elderly-appearing, pleasant female who currently is not in acute distress. Skin color and turgor are good. Pupils were equal and reactive to light. Conjunctivae clear. Throat is benign. Mucosa was moist and noncyanotic. Neck veins not distended at 90 degrees. Carotids had 2+ upstrokes bilaterally without bruits. No lymphadenopathy was appreciated. Chest had a normal AP diameter. The lungs were clear in the apices and bases, no wheezing or egophony appreciated. The heart had a normal S1, S2. No murmurs, clicks or gallops. The abdomen was soft, nontender, nondistended. Good bowel sounds present. No hepatosplenomegaly was appreciated. No pulsatile masses were felt. No abdominal bruits were heard. Her pulses are 2+ and equal bilaterally in the upper and lower extremities. No clubbing is appreciated. She is oriented x3. Demonstrated a good amount of strength in the upper and lower extremities. Face was symmetrical. She had a normal gait.
IMPRESSION: This is a (XX)-year-old female with significant multivessel coronary artery disease. The patient also has a left main lesion. She has undergone several PTCA and stenting procedures within the last year to year and a half. At this point, in order to reduce the risk of any possible ischemia in the future, surgical myocardial revascularization is recommended.
PLAN: We will plan to proceed with surgical myocardial revascularization. The risks and benefits of this procedure were explained to the patient. All questions pertaining to this procedure were answered.
Cardiology Consultation Sample #2
DATE OF CONSULTATION: MM/DD/YYYY
REFERRING PHYSICIAN: John Doe, MD
CONSULTING PHYSICIAN: Jane Doe, MD
HISTORY OF PRESENT ILLNESS: This (XX)-year-old lady is seen in consultation for Dr. John Doe. She has been under consideration for ventral hernia repair and has a background of aortic valve replacement and known coronary artery disease. The patient was admitted with complaints of abdominal pain, anorexia, and vomiting. She underwent a CT scan of the abdomen and pelvis and this showed the ventral hernia involving the transverse colon, but without strangulation. There was an atrophic right kidney. She had bilateral renal cysts. The hepatic flexure wall was thickened. There was sigmoid diverticulosis without diverticulitis. It has been recommended to her that she undergo repair of the ventral hernia. For this reason, cardiology consult is obtained to assess whether she can be cared from the cardiac standpoint.
PAST CARDIAC HISTORY: Bypass surgery. She underwent echocardiography and cardiac catheterization prior to the operation. Echocardiography showed an ejection fraction of 50%. There was marked left ventricular hypertrophy with septal wall 1.60 cm and posterior wall 1.55 cm. Coronary arteriography showed 90% stenosis in the anterior descending artery, situated distally just before the apex of the left ventricle. Only mild to moderate narrowing was seen elsewhere in the coronary circulation.
CORONARY RISK FACTORS: Her father had an irregular heartbeat and her brother had a fatal heart attack. She herself has had high blood pressure for 20 years. She has elevated cholesterol and takes Lipitor. She has had diabetes for 20 years. She is not a cigarette smoker. She does little physical exercise.
REVIEW OF SYSTEMS: CARDIOVASCULAR AND RESPIRATORY: She has no chest pain. She sometimes becomes short of breath if she walks too far. No cough. She has occasional swelling of her feet. Occasionally, she gets mildly lightheaded. Has not lost consciousness. She tends to be aware of her heartbeat when she is tired. She has no history of heart murmur or rheumatic fever. GASTROINTESTINAL: Recent GI symptoms as noted above, but she does not usually have such problems. She has had no hematemesis. She has no history of ulcer or jaundice. She sometimes has loose stools. No constipation and no blood in the stool. GENITOURINARY: She tends to have urinary frequency. She gets up once at night to pass urine. No dysuria, incontinence. She has had previous urinary infections. No stones noted. NEUROLOGIC: She has occasional headaches. No seizures. No trouble with vision, hearing, or speech. No limb weakness. MUSCULOSKELETAL: She tends to have joint and muscle pains and has a history of gout. HEMATOLOGIC: No anemia, abnormal bleeding, or previous blood transfusion. GYNECOLOGIC: No gynecologic or breast problems.
PAST MEDICAL HISTORY: She has had shoulder and hand injuries and has had carpal tunnel surgery. She has been diabetic and has been on insulin. She has chronic renal insufficiency with creatinine around 2.2. She has had hypothyroidism. She has had morbid obesity. She has chronic obstructive sleep apnea and uses BiPAP. She has had hysterectomy and oophorectomy in the past. Otherwise as noted above.
MEDICATIONS: Prior to hospital, she was taking glipizide XL 2.5 mg daily, metoprolol 50 mg b.i.d., Cipro 250 mg b.i.d., atorvastatin 40 mg daily, Synthroid 75 mcg daily, aspirin 81 mg daily, and Lantus 36 units daily. Currently, she is taking Lipitor 40 mg daily, Lantus 10 units at bedtime, Synthroid 75 mcg daily, metoprolol 50 mg b.i.d., and Zosyn 2.25 grams q.6h.
SOCIAL HISTORY: She does not drink alcohol.
PHYSICAL EXAMINATION:
GENERAL APPEARANCE: She is not currently dyspneic, in no distress. She is alert, oriented, and pleasant.
HEENT: Pupils are normal and react normally. No icterus. Mucous membranes well colored.
NECK: Supple. No lymphadenopathy. Jugular venous pressure not elevated. Carotids equal.
HEART: The heart rate is 82 per minute and regular and the blood pressure 132/78. The cardiac impulse has a normal quality. There is a grade 3/6 ejection systolic murmur heard medial to the apex and at the aortic area, with well heard radiation to the neck vessels.
CHEST: Chest is clear to percussion and auscultation. Normal respiratory effort.
ABDOMEN: Soft and nontender. The presence of a large ventral hernia is noted.
EXTREMITIES: There is no edema. Posterior tibial pulses were felt bilaterally, but I did not feel the dorsalis pedis.
SKIN: No rash or significant lesions are noted.
LABORATORY AND DIAGNOSTIC DATA: Electrolytes are normal. BUN and creatinine 18/2.2. Blood sugar 150. White count is 7.6, hemoglobin 11.7 with hematocrit 34.9, platelets 187,000. LFTs were normal. Hemoglobin A1c 7.7. TSH 1.82. Troponin I was normal on three occasions.
Chest x-ray showed an enlarged heart with postoperative changes, but no evidence of acute pathology. EKG shows probable left atrial enlargement. Low voltage QRS, probable inferior wall myocardial infarction and anterior wall infarction, age undetermined.
ASSESSMENT:
1. Aortic valve replacement with bioprosthetic valve. Residual systolic murmur.
2. Arteriosclerotic heart disease with severe stenosis in anterior descending artery, but this is situated distally and subtends only a small mass of myocardium.
3. Well preserved left ventricular systolic function. The EKG appearance of previous myocardial infarction is probably serious, indicating multiple other medical problems as listed above and also documented in the chart.
RECOMMENDATIONS: It appears that she does not wish to proceed with the surgery at this time, and if such surgery is not urgently required, then I would simply recommend that she resume her previous preadmission medical program. If, however, the surgery is felt to be urgently needed and she changes her mind and wishes to proceed, then I think this can be done without excessive cardiovascular risk.
Given the recent evaluations, I do not think additional cardiac testing would be needed at this time. She should of course receive the usual precautions for cardiac patients undergoing surgery, including careful watch of EKG perioperatively, with observation of heart rate, blood pressure, and fluid and electrolyte balance. Additionally, she would require appropriate antibiotic prophylaxis to protect the bioprosthetic valve against endocarditis.
Thank you very much for asking me to see this patient. I will be pleased to follow her further in the hospital upon request.
Cardiology Consultation Sample #3
DATE OF CONSULTATION: MM/DD/YYYY
REFERRING PHYSICIAN: John Doe, MD
CONSULTING PHYSICIAN: Jane Doe, MD
REASON FOR CONSULTATION: Surgical evaluation for coronary artery disease.
HISTORY OF PRESENT ILLNESS: This is a (XX)-year-old female who developed a 3- to 4-month history of some crescendoing exertional dyspnea symptoms. Prior to admission, she started to note profound shortness of breath after walking about two flights of stairs. She has never noted any chest pain. She was seen by her primary care physician after having a severe episode of dyspnea and diaphoresis. When she was seen, she was found to be hypotensive and tachycardic. She was admitted for further observation and workup. CT scan of the head ruled out any acute CVA. Her EKG showed some nonspecific ST segment changes. Echocardiography showed a normal left ventricle with some mild hypertrophy. A carotid duplex scan was also obtained and this was essentially unremarkable for any significant carotid artery stenosis. An adenosine Cardiolite stress test was obtained and this was suggestive of some ischemia, which prompted a cardiac catheterization on MM/DD/YYYY. Through this, an 80% lesion to the left anterior descending artery was identified. The circumflex system had about an 80% stenosis. The posterior descending artery had about a 70% stenosis. In view of these findings, surgical consultation was requested and the patient was seen and evaluated by Dr. Doe.
PAST MEDICAL HISTORY:
1. Coronary artery disease, as described above.
2. Hypertension.
3. Insulin-dependent diabetes mellitus.
ALLERGIES: None.
MEDICATIONS: Medications that she was taking prior to admission included Vasotec, Glucophage, hydrochlorothiazide, Actos and Coreg. She is also taking Lantus insulin.
SOCIAL HISTORY: She does not smoke. She does not abuse alcohol. She is fairly active.
FAMILY MEDICAL HISTORY: Significant for premature coronary artery disease in both her mother’s and father’s sides.
REVIEW OF SYSTEMS: No history of any CVAs, TIAs or seizures. She complains of chronic headaches. No asthma, TB, hemoptysis or productive cough. There is no congenital heart abnormality or rheumatic fever history. She has never had any chest pain. There is no nausea, vomiting, constipation, diarrhea, melena, peptic ulcer disease or any gastrointestinal problems. There are no thyroid problems, but she does have a history of insulin-dependent diabetes mellitus with peripheral neuropathies and a left footdrop. There are no musculoskeletal disorders or history of gout. There are no kidney or liver problems. There is no dysuria, hematuria or frequency. She has no depression or psychiatric problems. There is no hematologic problem or blood dyscrasias. There are no recent fevers, malaise, changes in appetite or change in weight.
PHYSICAL EXAMINATION: Blood pressure is 138/70. She is in sinus rhythm on the EKG monitor with a rate of about 78. Respirations were 18 and unlabored. Temperature 97.8 degrees Fahrenheit. General: This is a middle-aged, pleasant-appearing female who is currently not in any acute distress. Her skin color and turgor are good. Pupils are equal and reactive to light. Conjunctivae clear. Throat is benign. Mucosa moist and noncyanotic. Neck veins were about 2 to 3 cm at 45 degrees. Carotids had 2+ upstrokes bilaterally. I did not hear any bruits. No lymphadenopathy was appreciated. Chest had a normal AP diameter. Lungs were essentially clear in the apices and bases. No wheezing or galloping appreciated. Heart had a normal S1, S2. No murmurs, clicks or gallops. Abdomen was soft, nontender and nondistended. Good bowel sounds present. No hepatosplenomegaly appreciated. No pulsatile masses felt. No abdominal bruits heard. Pulses were 2+ and equal bilaterally in the upper extremities. Femoral pulses were 1+ bilaterally. A hematoma was noted in the right groin; this did extend into the thigh. The pedal pulses were 1+ bilaterally. Greater saphenous veins distended well. She was oriented x3. She demonstrated good equal bilateral strength in the upper extremities. In the lower extremities, she had good strength on the right side and there was subtle left footdrop noted.
IMPRESSION: This is a (XX)-year-old female who has significant multivessel coronary artery disease. She has atypical anginal symptoms, which are probably secondary to her insulin-dependent diabetes mellitus. Nonetheless, she is at risk for ischemia, and in order to reduce this risk, surgical myocardial revascularization is recommended.
PLAN: Proceed with coronary artery bypass graft operation utilizing the left internal mammary artery as conduit to the left anterior descending. The remaining conduit will come from the greater saphenous veins. The risks and benefits of this procedure were explained to the patient.
