DATE OF CONSULTATION: MM/DD/YYYY
REFERRING PHYSICIAN: John Doe, MD
REASON FOR CONSULTATION: Chest pain.
HISTORY OF PRESENT ILLNESS: The patient is a very pleasant (XX)-year-old Hispanic female. She has multiple coronary risk factors, known history of coronary artery disease, status post percutaneous intervention, status post catheterization which showed patency of the stent, as per her. About a week ago, she had some upper respiratory and sinus infection. She was getting over it, and then over the weekend, over the last 2 to 3 days, she has been having some intermittent episodes of chest pain which was left parasternal and left precordial in nature with some occasional radiation to the left shoulder and left side of neck and left side of the back. This is more exertional in nature. It is not pleuritic. There is a pressure-like sensation and is moderate in intensity. There is some associated shortness of breath, but she does have also some chronic shortness of breath. She denies any diaphoresis, nausea, vomiting, palpitation, dizziness, or syncope. Her symptoms gradually became more worse, and this morning, she had a more prolonged episode and went to the local clinic. She was given two sublingual nitroglycerin and her discomfort improved, and she was transferred to the ED here. When she arrived here, her vital signs were stable. She is being treated with 1/2-inch nitroglycerin paste currently. She is chest pain free. She denies any recent orthopnea, PND, lower extremity edema, intermittent claudication or palpitation, dizziness, syncope.
PAST MEDICAL HISTORY: Significant for COPD, history of hypertension, hyperlipidemia, and history of coronary artery disease, status post percutaneous intervention. No history of CHF.
PAST SURGICAL HISTORY: Cervical spinal fusion, hysterectomy, carpal tunnel surgery, and trigger finger surgery.
FAMILY HISTORY: Noncontributory.
MEDICATIONS: Norvasc 5 mg daily, Advair, Singulair, Nexium, Cozaar 50 mg daily, Plavix 75 mg daily, Zocor 40 mg at bedtime, Imdur 60 mg daily, aspirin 325 mg daily.
ALLERGIES: PENICILLIN.
SOCIAL HISTORY: The patient is divorced. She denies any current smoking, alcohol or drug abuse.
REVIEW OF SYSTEMS: As mentioned above. Otherwise, no abdominal or genitourinary complaint. No focal weakness or paresthesias of any extremities. No recent skin rashes. No swelling or pain in the joint.
PHYSICAL EXAMINATION:
GENERAL: The patient is alert and oriented x3, in no apparent distress. She is moderately obese.
VITAL SIGNS: Blood pressure is 110/58, heart rate 60 per minute, respiratory rate 18 per minute, pulse oximetry 97%.
HEENT: Pupils equally round and reactive to light and accommodation. Extraocular movements are intact. Sclerae is anicteric. There is no oropharyngeal congestion.
NECK: Supple. No JVD. Bilateral carotids are 2+. No bruit. No thyromegaly or lymphadenopathy.
CHEST: Clear to auscultation and percussion.
HEART: S1 and S2 normal. There is no S3 or S4. There is a 2 to 3/6 early-peaking systolic ejection murmur at the base with very mild radiation to the right side of the carotid. Apical impulse is nondisplaced.
ABDOMEN: Soft, nontender with no organomegaly. Bowel sounds are present and normal local tenderness with the bruits.
EXTREMITIES: No pedal edema, cyanosis or clubbing.
NEUROLOGIC: Grossly nonfocal.
SKIN: No rashes.
MUSCULOSKELETAL: No joint swelling or tenderness.
LABORATORY AND DIAGNOSTIC DATA: EKG done showed normal sinus rhythm, rate of 60 per minute and nonspecific anterior T-wave abnormality. Cannot exclude ischemia. No old EKG to compare with this. Repeat EKG done this morning showed normal sinus rhythm, rate 58 per minute and nonspecific anterior T-wave abnormality. Cannot exclude ischemia. EKG done prior showed similar findings. There is some artifact present as well. Her CBC was within normal limits. Her coagulation profile at baseline normal. BMP is normal. First set of CPK and troponin are normal. Her chest x-ray showed no evidence of any congestive heart failure, pneumonia or pleural effusion.
IMPRESSION:
1. This is a (XX)-year-old female with multiple coronary risk factors and known history of coronary artery disease, prior percutaneous intervention, who was presenting with a recent onset of intermittent chest pain, which is suspicious for unstable angina. Her electrocardiogram shows nonspecific T-wave abnormality anteriorly. Her first set of cardiac enzymes are negative. She did have a response to nitroglycerin. Currently, she is chest pain free. No evidence of congestive heart failure. She needs further evaluation and monitoring.
2. History of coronary artery disease, status post percutaneous intervention.
3. Hypertension, under control.
4. Hyperlipidemia, on therapy.
5. History of chronic obstructive pulmonary disease.
PLAN AND RECOMMENDATION:
1. Agree with admission and telemetry.
2. Will obtain serial cardiac enzymes.
3. Treat with aspirin and Plavix and also Lovenox 1 mg/kg subcutaneously q. 12 hours.
4. Continue home medications, also nitroglycerin paste.
5. Echocardiogram to evaluate LV function and assess for any wall motion abnormality.
6. Check a fasting lipid profile in the morning. Target LDH should be less than 70 mg/dL.
7. If she rules out for myocardial infarction, we will proceed with adenosine dual-isotope nuclear stress test in the morning.
8. If her cardiac enzymes are abnormal and she continues to have the current chest pain, she will proceed with the cardiac catheterization, which was discussed with the patient. She is agreeable.
9. Further recommendation to follow.
Thank you, Dr. Doe, for allowing us to participate in the care of this patient.
