DATE OF CONSULTATION: MM/DD/YYYY
REFERRING PHYSICIAN: John Doe, MD
REASON FOR CONSULTATION: Atrial fibrillation with a fast ventricular response.
HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old male who states last night he felt his heart start racing. He states he had slight sweating associated as well as slight lightheadedness. The patient then came to the emergency room because he thought he was back into atrial fibrillation, which indeed he was. The patient states he had a similar episode in the past. The patient states he was found to have atrial fibrillation with a fast ventricular response and was later cardioverted a few months later. The patient denies dyspnea on exertion, orthopnea, paroxysmal nocturnal dyspnea, syncope, or lightheadedness.
Risk factors for coronary artery disease, negative.
PAST MEDICAL HISTORY: As above and eye surgery.
MEDICATIONS: Coreg 12.5 mg b.i.d., Synthroid 100 mcg daily.
ALLERGIES: No known drug allergies.
FAMILY HISTORY: Negative for myocardial infarction.
SOCIAL HISTORY: The patient denies smoking. The patient drinks alcohol seldomly.
REVIEW OF SYSTEMS: The patient hematemesis, melena, hematochezia, hemostasis, hematuria. Denies transient localized weakness or visual change. Denies history of asthma or wheezing. Denies recent weight change. Denies pain in joints or muscles.
PHYSICAL EXAMINATION:
VITAL SIGNS: Today, pulse 120, blood pressure 118/66, and respiratory rate of 18.
GENERAL: The patient is a pleasant Hispanic male, in no apparent distress.
HEENT: Pupils are equal and round. Mucosa and conjunctivae pink.
NECK: No increased JVD or bruits.
CHEST: Clear to percussion and auscultation.
CARDIAC: PMI is not palpable. S1 and S2, normal. No S3 or murmur.
ABDOMEN: Soft, nontender, no hepatosplenomegaly.
EXTREMITIES: No clubbing, cyanosis, or edema. Dorsalis pedis pulses intact.
PSYCHIATRIC: The patient is oriented x3.
LABORATORY AND DIAGNOSTIC DATA: EKG: Atrial fibrillation, nonspecific ST-T wave changes. Creatinine 1.3, BUN of 16, potassium 3.9, hemoglobin 16, WBC 7.4. D-dimer less than 0.44. TSH 3.56. Free T4 of 1.54. Troponin less than 0.1 x2. Magnesium 1.8. B-type natriuretic peptide level 1. Previous echocardiogram, left ventricular enlargement. Left ventricular ejection fraction of 45% to 50%.
IMPRESSION:
1. Atrial fibrillation, recurrent with history of cardioversion in the past.
2. History of cardiomyopathy. Previous echocardiogram with left ventricular ejection fraction of 45% to 50%.
RECOMMENDATIONS: The patient was advised to increase Coreg. Subcutaneous Lovenox to Coumadin anticoagulation. Discuss consideration of Betapace with the patient. Consider ACE inhibitor.
Thank you, Dr. Doe, for asking us to see this patient. We will follow along with you.
