DATE OF CONSULTATION: MM/DD/YYYY
REFERRING PHYSICIAN: John Doe, MD
REASON FOR CONSULTATION: Chest pain and abnormal EKG.
HISTORY OF PRESENT ILLNESS: This (XX)-year-old Hispanic female was admitted through the emergency department with a complaint of chest pain. It was noted that her EKG had nonspecific T-wave inversions in leads III and V1, which was changed from a previous EKG. She states that her chest pain has been present for approximately 3 days and is not associated with specifically rest or activity. She states that the pain is 1/10 on the pain scale. She denies any shortness of breath, nausea, or diaphoresis. She does not have any previous history of chest pain and no previous cardiac testing. Cardiac enzymes have been normal x3. D-dimer is 0.24.
PAST MEDICAL HISTORY: Asthma.
PAST SURGICAL HISTORY: None.
ALLERGIES: None.
MEDICATIONS: Albuterol.
FAMILY HISTORY: Negative for coronary artery disease. She does have a brother with hypertension. No family history of diabetes mellitus.
SOCIAL HISTORY: The patient is married. Denies any history of smoking, alcohol use, or drug use.
REVIEW OF SYSTEMS: Negative, expect for those listed above.
PHYSICAL EXAMINATION:
VITAL SIGNS: Temperature 98.6 degrees, pulse 66, respiratory rate 18, blood pressure 132/76, and oxygen saturation 98% on room air.
GENERAL: This is a (XX)-year-old Hispanic female. She is alert and oriented, resting comfortably in bed, in no acute distress at this time.
HEENT: Head is normocephalic and atraumatic. Eyes are clear without discharge. Ocular movement is intact.
LUNGS: Clear to auscultation anteriorly and posteriorly.
HEART: Regular rate and rhythm. S1 and S2 present. The patient does have a 2/6 systolic ejection murmur noted at the left sternal border.
ABDOMEN: Obese, soft, and nontender. Bowel sounds present.
EXTREMITIES: No distal edema, clubbing, or cyanosis. Dorsal pedis pulses 2+, bilaterally symmetrical.
NEUROLOGICAL: No gross neurological deficits appreciated at this time.
DIAGNOSTIC DATA: WBC 7.4, hemoglobin 13.4, hematocrit 39.2, and platelets 376,000. APTT 28.2, PT 14.8, INR 1.14. D-dimer 0.24. Sodium 136, potassium 3.7, chloride 104, CO2 of 26, BUN 10, creatinine 0.9, magnesium 1.9. CPK 148, 132, 130 and CK-MB 1.5, 1.3, 1.2. Troponin 0.00, 0.00, and 0.00. Chest x-ray: Lungs clear.
CARDIAC RISK FACTORS: Family history of hypertension, obesity, and sedentary lifestyle.
IMPRESSION:
1. Chest pain, atypical, and unclear etiology but EKG changes noted.
2. Borderline blood pressure.
3. Obesity.
PLAN:
1. We will check a 2D echocardiogram to evaluate valve, ejection fraction, and wall motion.
2. We will schedule the patient for a two-day Myoview stress test. The patient’s chest pain is atypical, but she has diffuse T-wave changes that have resolved. She may have gallbladder disease, which can also produce these EKG changes.
Thank you for allowing us to participate in this patient’s care. We will continue to follow her with you.
