DATE OF CONSULTATION: MM/DD/YYYY
REFERRING PHYSICIAN: John Doe, MD
REASON FOR CONSULTATION: Episode of bradyarrhythmia.
HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old Caucasian female with a past medical history of hypertension, paroxysmal atrial fibrillation, and diffuse osteoarthritis. The patient presented to the emergency department with a complaint of atypical chest pain, mostly in the upper shoulder and both arms and radiating into the back. Cardiac enzymes were negative. EKG showed atrial fibrillation with no acute ST or T wave changes. The patient underwent an adenosine Myoview stress test, which was reported to be negative.
The patient was scheduled to be discharged home when she was noticed to have an episode of atrial fibrillation with very slow ventricular response. Heart rate was ranging in the 30s. During this episode, the patient was feeling dizzy and lightheaded associated with significant fatigue and weakness. Cardiology consultation was requested for further evaluation and treatment. Last year, her 2D echo was showing normal left ventricular size and systolic function, sclerotic aortic valve, and no evidence of stenosis. No significant regurgitation noted.
PAST SURGICAL HISTORY: Includes hysterectomy, cholecystectomy, and cataract surgery.
MEDICATIONS: She is on Diovan, hydrochlorothiazide, digoxin, potassium supplement, diclofenac, and Tylenol.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: The patient denies smoking, ETOH abuse or drug abuse.
FAMILY HISTORY: Noncontributory.
REVIEW OF SYSTEMS:
CONSTITUTIONAL: The patient is denying any visual or hearing disturbances. She denies any difficulty swallowing, change in appetite or weight.
CARDIOVASCULAR: She had a history of paroxysmal atrial fibrillation. Currently, the patient is in atrial fibrillation with unknown duration of her current episodes. No history of CHF. She denies any PND, orthopnea or leg swelling. No history of frank syncope reported.
RESPIRATORY: She had a history of sleep apnea. She is on CPAP support. She denies any COPD, asthma or recurrent pneumonia.
GASTROINTESTINAL: She denies any nausea, vomiting, diarrhea or constipation. She does have a history of gastroesophageal reflux disease.
GENITOURINARY: She denies any frequency, dysuria, or change in the color of the urine.
NEUROLOGIC: She denies any TIA, strokes or significant headache.
PHYSICAL EXAMINATION:
GENERAL: The patient is awake, alert, and oriented x3, not in acute respiratory distress.
VITAL SIGNS: Blood pressure 140/68, pulse 50 and irregular, respiratory rate 14, and temperature afebrile.
HEENT: Head is normocephalic. Pupils are equal and reactive to light. Sclerae nonicteric.
NECK: Supple. JVD negative. No carotid bruit. No lymphadenopathy or thyromegaly.
HEART: S1, S2 normal. Irregularly regular. Systolic murmur 2/6 in the aortic position.
CHEST: Shows air entry fair bilaterally. No rales, no wheezing.
ABDOMEN: Soft. Bowel sounds positive. No organomegaly or masses.
EXTREMITIES: Edema negative, femoral pulses are 2+ bilaterally.
NEUROLOGIC: No focal neurologic deficits. Cranial nerves II through XII are grossly intact.
DIAGNOSTIC DATA: Her EKG is showing atrial fibrillation with ventricular response at 94 beats per minute, left axis deviation, nonspecific intraventricular conduction defect, an old anteroseptal infarct, age undetermined, lateral ST-T wave changes, nonspecific. Her EKG is showing atrial fibrillation with ventricular response of 70, ventricular premature contraction, and borderline intraventricular conduction defect, diffuse nonspecific T wave changes.
Cardiac telemetry showed an episode of atrial fibrillation with a slow ventricular response, heart rate ranging between 30 and 40 at that time, and the patient was symptomatic during those episodes.
LABORATORY DATA: No recent labs seen. Lab from two days ago showed WBC 6.8, hemoglobin and hematocrit 11.8 and 36.8, platelet count 158. PT and INR normal. D-dimer was 0.4. Sodium 138, potassium 3.6, chloride 98. BUN and creatinine 14 and 1.0. Cardiac enzymes x3 were negative and BNP was 178.
IMPRESSION:
1. Atrial fibrillation with a slow ventricular response, symptomatic, with a heart rate between 30 and 40 at that time.
2. Hypertension.
3. Osteoarthritis.
4. Gastroesophageal reflux disease.
PLAN: The plan is to hold digoxin at this point and check digoxin level. Continue monitoring. If the patient continues to be bradycardic, she may need permanent pacemaker implantation. The patient also will require anticoagulation with Coumadin with adjusted INR of 2 to 3 if no other contraindications, but we will hold off on the Coumadin until we decide about permanent pacemaker implantation. Further recommendations according to hospital course.
