DATE OF CONSULTATION: MM/DD/YYYY
REFERRING PHYSICIAN: John Doe, MD
REASON FOR CONSULTATION: Thoracic aneurysm and pericardial effusion.
HISTORY OF PRESENT ILLNESS: The patient is an (XX)-year-old African-American female who was brought to the emergency department after she experienced right eye pain that began on Saturday and then had double vision. The patient saw an optometrist here in the area, and they instructed her to come to the ED. After an hour in the ED, the pain and the double vision went away. The patient has been seen by Neurology. The patient has a history of a known aneurysm for 4-5 years; this is according to the son. The patient has a history of hypertension, asthma, history of an arrhythmia, and osteoporosis. Currently, the patient denies any complaints of chest pain, shortness of breath, palpitations, lightheadedness, dizziness, or syncope. No nausea, no vomiting, no diaphoresis.
PAST MEDICAL HISTORY: As stated in the history of present illness.
PAST SURGICAL HISTORY: Gallbladder surgery, appendectomy, hysterectomy, and hemorrhoidectomy.
ALLERGIES: PENICILLIN.
MEDICATIONS: Cozaar 50 mg p.o. daily, diltiazem 120 mg p.o. daily, amiodarone 100 mg p.o. Monday and Friday, Solu-Medrol, and multivitamin.
SOCIAL HISTORY: The patient denies use of alcohol, tobacco, or illicit drug use.
FAMILY HISTORY: Noncontributory.
REVIEW OF SYSTEMS: Negative for headache and blurred vision currently. No chest pain. No trouble breathing. No dyspnea. No orthopnea. No lightheadedness, dizziness, or palpitations. No diaphoresis. No nausea. No vomiting. No abdominal pain. No GI bleed or hematuria. History of GI bleed. No kidney disease, thyroid disease, or liver disease. No CVA or TIA history. No fever. No chills. No edema. The patient does have a history of edema.
PHYSICAL EXAMINATION:
VITAL SIGNS: Temperature 98.4, pulse 66, respirations 18, blood pressure 122/76.
GENERAL: This is a well-nourished female who is in no apparent distress. The patient is alert and oriented to person, place, and time.
HEENT: Pupils are equal, round, reactive to light and accommodation. Normocephalic.
NECK: No thyromegaly. No carotid bruits. No JVD.
HEART: Regular rate and rhythm. Normal S1 and S2. No S3 or S4. No murmurs, rubs, or clicks.
LUNGS: Clear to auscultation bilaterally.
ABDOMEN: Soft and nontender with positive bowel sounds in all 4 quadrants.
EXTREMITIES: No edema noted in bilateral lower extremities, +2 dorsalis pedis pulses noted bilaterally.
NEUROLOGIC: No focal deficits.
LABORATORY DATA: White count 9000, hemoglobin 11.6, hematocrit 34.8, platelets 234,000. Sodium 141, potassium 3.8, chloride 106, CO2 of 26, glucose 84, BUN 14, and creatinine 0.9. Cardiac enzymes were negative x1.
DIAGNOSTIC STUDIES: EKG: Normal sinus rhythm. No acute changes.
IMPRESSION:
1. Small pericardial effusion seen on CAT scan.
2. Thoracic aneurysm, for 4-5 years, according to the son’s history.
3. History of hypertension, on Cozaar at home.
4. History of arrhythmia, on diltiazem and amiodarone. Exact arrhythmia not known.
5. History of asthma.
6. Rule out transient ischemic attack. The patient has been seen by Neurology.
PLAN: We will review echocardiogram. Continue current medications. Cozaar 50 mg p.o. daily, diltiazem 120 mg p.o. daily, and amiodarone 100 mg p.o. on Monday and Friday. We will discuss with Cardiology attending.
Thank you, Dr. John Doe for this consult. We will follow along with you.
