DATE OF CONSULTATION: MM/DD/YYYY
REFERRING PHYSICIAN: John Doe, MD
CHIEF COMPLAINT: Left arm pain.
HISTORY OF PRESENT ILLNESS: The patient is a very pleasant (XX)-year-old female who has numerous underlying comorbidities, including known moderate diffuse atherosclerotic coronary artery disease by cardiac catheterization. She is on aggressive medical therapy as an outpatient. The patient also has underlying obstructive sleep apnea, chronic obstructive pulmonary disease, history of DVT with pulmonary embolism and resultant pulmonary hypertension. The patient has morbid obesity, hypothyroidism, and dyslipidemia, as well as hypertension. She also suffers from diabetes mellitus and underlying Clostridium difficile colitis.
The patient states she has been in her usual state of health when she experienced left arm pain. This occurred at rest while talking to a friend and was consistent with previous angina. The patient states the pain lasted approximately 6 minutes before she notified the nurse, who promptly gave her 3 sublingual nitroglycerins, which did not relieve the pain. The pain resolved spontaneously about 10 minutes later. The patient states her blood pressure has been stable. She has been noticing increasing anginal symptoms over the past 6 to 8 months as well. Currently, she denies any chest pain or pressure, no lightheadedness, or dizziness, no shortness of breath or dyspnea on exertion. She does have recurrent diarrhea but states that this has improved today as well.
PAST MEDICAL HISTORY: Significant as above.
CURRENT MEDICATIONS: Lovenox 40 mg daily, Flagyl 500 mg q.8 h., Lasix 40 mg daily, Protonix 40 mg daily, Lipitor 10 mg daily, Cozaar 50 mg daily, doxepin 25 mg daily, aspirin 81 mg daily, sliding scale insulin, Synthroid 0.125 mg daily, theophylline 300 mg b.i.d., potassium chloride 20 mEq daily, Nitro-Dur patch 0.3 mg per hour daily, and Coumadin 3.5 mg daily.
ALLERGIES: NKDA.
SOCIAL HISTORY: No tobacco, no alcohol.
FAMILY HISTORY: Noncontributory.
REVIEW OF SYSTEMS: As above, otherwise negative x13 systems.
PHYSICAL EXAMINATION: Blood pressure is stable at 132/56, pulse is 86 and regular, respirations 20, and O2 saturation 98% on 4 liters nasal cannula. The patient is afebrile. Telemetry shows sinus rhythm. General: The patient is a morbidly obese female appearing approximately her stated age, resting comfortably in exam room, in no acute distress. She is appropriate and oriented. HEENT: Normocephalic and atraumatic. Neck: No jugular venous distention. No carotid bruits. No thyromegaly or goiter. Trachea is midline. Neck is supple. Lungs: Clear bilaterally. Cardiac: S1, S2 maintained. Regular rate. No additional heart sounds. Abdomen: Benign, although morbidly obese. Extremities: Bilateral trace edema in the pedal area. Neurologic: Grossly within normal limits. Gastrointestinal: Deferred. Genitourinary: Deferred.
DIAGNOSTIC DATA: EKG upon admission shows a normal sinus rhythm with nonspecific ST-T wave changes and borderline intraventricular conduction delay. Chest x-ray shows cardiomegaly with pulmonary infiltrates.
LABORATORY DATA: Sodium 138, potassium 4.4 up from 3.8, chloride 102, CO2 of 29, BUN 12, creatinine 0.9, glucose 106. White count is 4.6, hemoglobin 10.6, hematocrit 33.0, platelets 206,000. Triglycerides 136, total cholesterol 105, HDL 54, LDL 84, CK 132 to 115, CK-MB 2.0 to 1.8, troponin I is less than 0.02 x2, B-natriuretic peptide is 23. INR is 1.66 today, down from 1.80.
IMPRESSION:
1. Left arm pain consistent with previous anginal symptoms. This is occurring at rest and is becoming more frequent.
2. Moderate diffuse coronary artery disease by cardiac catheterization. The patient is not a candidate for percutaneous coronary intervention or coronary artery bypass grafting secondary to coronary anatomy.
3. Morbid obesity.
4. History of deep venous thrombosis with pulmonary embolism and significant pulmonary hypertension.
5. Chronic obstructive pulmonary disease.
6. Hypothyroidism.
7. Clostridium difficile colitis, on antibiotics.
8. Diabetes mellitus type 2.
9. Dyslipidemia.
PLAN: The patient is stable from a cardiac standpoint. She is not a candidate for further intervention at this time secondary to known coronary anatomy, which is not amenable to PCI or coronary bypass grafting. She does complain of worsening recurrent angina, however. Therefore, we will intensify medical therapy from a cardiac standpoint. Further recommendations depending on hospital course and as per orders on the chart.
