DATE OF CONSULTATION: MM/DD/YYYY
REFERRING PHYSICIAN: John Doe, MD
REASON FOR CONSULTATION: Heart failure.
HISTORY OF PRESENT ILLNESS: This is a (XX)-year-old female who started having shortness of breath approximately three to four days ago. She has a history of heart disease and congestive heart failure. The patient was becoming more short of breath and O2 saturations were declining, and therefore, she was admitted for treatment. The patient denies any dizziness, syncope, chest pain, or nausea. She has noticed more shortness of breath, especially when lying down or with any mild activity. The patient is followed in our office and has had echocardiogram. The last one showed mild aortic insufficiency, mild mitral regurgitation, and tricuspid regurgitation with increased PA pressure of 50. Ventricular hypertrophy was noticed as well and a normal ejection fraction. The patient had a history of myocardial infarction having undergone PTCA and stent placement in her left circumflex, left anterior descending, and marginal.
PAST MEDICAL HISTORY: Significant for congestive heart failure, heart disease, hypokalemia, anemia, hiatal hernia, CDT colitis, deep venous thrombosis, hyperlipidemia, hypertension, COPD, and syncope, thought to be secondary to orthostatic hypotension.
PAST SURGICAL HISTORY: PTCA and stenting as described above.
ALLERGIES: NKDA.
MEDICATIONS: Coreg, aspirin, Pepcid, Paxil, Plavix, Florinef, Catapres, and Lipitor.
FAMILY HISTORY: Noncontributory.
SOCIAL HISTORY: The patient denies any alcohol, drug, or tobacco use.
REVIEW OF SYSTEMS: The patient denies any chills or fevers. The patient has been noticing a tickling dry cough but no production of sputum. She denies any changes in her bowels or urinary patterns. The patient denies any dizziness, syncope, or palpitations. She has not noticed any increasing swelling or pain in her lower extremities. She denies any headaches, visual disturbances, or localized extremity weakness or paraesthesias.
PHYSICAL EXAMINATION:
GENERAL: This is a (XX)-year-old Hispanic female who is alert and oriented and does not appear to be in any distress.
VITAL SIGNS: Blood pressure is 184/74, heart rate 66, respirations 18, temperature is 97.8 degrees, and saturations 94% on 2 liters via nasal cannula.
HEENT: Pupils are round and reactive to light equally. They demonstrate evidence of previous cataract surgery. Oral mucosa is pink and somewhat dry.
NECK: Supple. No jugular venous distention, carotid bruit, or thyromegaly noted.
LUNGS: Clear to auscultation bilaterally.
HEART: S1 and S2 audible without murmurs, rubs, or gallops. Rate and rhythm are regular.
ABDOMEN: Soft and nontender with positive bowel sounds.
EXTREMITIES: Show no evidence of peripheral edema. Pedal pulses are 2+ bilaterally.
DIAGNOSTIC STUDIES: Chest x-ray showed interstitial edema as well as pleural effusions. EKG showed normal sinus rhythm at a rate of 66 with low voltage and anterolateral ST-T wave abnormalities.
LABORATORY DATA: Cardiac enzymes negative x3. WBC 6.2, hemoglobin 10.8, hematocrit 32.9, platelets are 294,000. Sodium 138, potassium 3.2, chloride 102, CO2 of 31, BUN 14, creatinine 0.7, and glucose 114. ALT and AST within normal limits. BNP was 1060.
IMPRESSION:
1. History of congestive heart failure, presently with decompensation and improved after Lasix diuresis.
2. History of coronary artery disease, status post myocardial infarction and stents x3.
3. Hypokalemia.
4. Hiatal hernia.
5. History of deep venous thrombosis.
6. History of dyslipidemia.
7. Uncontrolled hypertension.
8. Chronic obstructive pulmonary disease.
9. History of syncope, status post echocardiogram showing normal ejection fraction.
10. History of Clostridium difficile toxin colitis.
11. Anemia.
12. Hyperlipidemia, treated with statin.
PLAN:
1. Continue Lasix as ordered.
2. Increase Coreg and add Altace for uncontrolled hypertension.
3. Replace potassium as needed.
4. We will perform adenosine Myoview since the patient has not had a stress test since her stenting.
Thank you very much for allowing us to participate in the care of your patient.
