DATE OF ADMISSION: MM/DD/YYYY
REASON FOR ADMISSION: The patient is to be admitted for elective cardiac catheterization.
HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old Hispanic female being admitted for elective cardiac catheterization. The patient had an abnormal stress echocardiogram, treadmill test done in which she exercised for 5 minutes and 30 seconds. Resting echocardiographic images demonstrated marked inferior apical hypokinesia, which did not improve post stress. The patient had anteroseptal hypokinesia, which worsened with exercise. The patient reports that, in April, she had four episodes of epigastric pain. She states that the first two episodes were short, lasting 10-30 minutes in duration. The patient states that the last episode was more severe and lasted for about an hour. She states that the episodes occurred while she was walking on a hot day. She states with that episode, she felt nervous. She denies other associated symptoms. She denies chest pain for the past three months. The patient states shortness of breath with three flights of stairs, which she attributes to smoking. The patient denies orthopnea, paroxysmal nocturnal dyspnea, syncope.
PAST MEDICAL HISTORY: The patient has a history of hypertension and hypercholesterolemia. The patient is status post appendectomy and cholecystectomy.
MEDICATIONS: Lipitor 40 mg daily, fish oil, Fosamax 35 mg weekly, Prilosec 20 mg daily, calcium and vitamin D, Altace 5 mg, and Ecotrin 81 mg p.o. daily.
ALLERGIES: NO KNOWN DRUG ALLERGIES.
FAMILY HISTORY: Negative for myocardial infarction.
SOCIAL HISTORY: The patient smokes one-half pack per day. The patient has decreased from one pack per day about three months ago. The patient denies alcohol for the past 10 years, stating she has been sober with Alcoholics Anonymous.
REVIEW OF SYSTEMS: The patient states that she has had a recent sore throat. The patient denies weight change. The patient denies abdominal pain. The patient denies hematemesis, melena, hematochezia, hemoptysis, and hematuria. The patient denies transient localized weakness or visual change. The patient denies history of wheezing. The patient denies pain in muscles or joints. Review of systems, otherwise, negative.
PHYSICAL EXAMINATION:
VITAL SIGNS: Pulse 96, blood pressure 178/110, respiratory rate 18.
GENERAL: The patient is a pleasant Hispanic female, in no apparent distress.
HEENT: Pupils equal and round. Mucosa and conjunctivae pink.
NECK: No increased JVD. Soft, left carotid bruit.
CHEST: Clear to percussion and auscultation.
CARDIAC: PMI is not palpable. S1 and S2 are normal. No S3 or murmur.
ABDOMEN: Soft. Nontender. No hepatosplenomegaly.
EXTREMITIES: No clubbing, cyanosis, or edema, 2+ dorsalis pedis pulses.
PSYCHIATRIC: Alert and oriented x3.
IMPRESSION:
1. Coronary artery disease by history. The patient may have had a myocardial infarction in April. The patient with abnormal stress echocardiogram.
2. Hypertension.
3. Hypercholesterolemia.
4. Smoker.
5. Cerebrovascular disease.
PLAN: The patient is to undergo cardiac catheterization. The risk and benefits have been discussed with the patient, including the risk of bleeding which could require a blood transfusion, damage to artery in leg which could require surgical repair, heart attack, stroke, allergic reaction, and renal failure.
