DATE OF CONSULTATION: MM/DD/YYYY
REFERRING PHYSICIAN: John Doe, MD
REASON FOR CONSULTATION: CHF.
HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old Hispanic female with a history of nonischemic cardiomyopathy, ejection fraction 35%, status post ICD, BiV, history of malignant right pleural effusion secondary to metastatic breast carcinoma, history of moderate to severe MR and aortic incompetence, hypertension, history of renal insufficiency, diabetes mellitus, and paroxysmal atrial fibrillation who presents with complaints of increased dyspnea on exertion. The patient also states that she felt like she was going to collapse and lose consciousness. This was occurring more frequently and this feeling had become worse. She states that she feels her device kicking in to pace her. On ED admission, her BNP was 570, and she was placed on a Natrecor drip. Currently, she is stating that her shortness of breath is better. She denies chest pain, palpitations, dizziness, lightheadedness, and syncope.
PAST MEDICAL HISTORY: As stated in the history of present illness.
PAST SURGICAL HISTORY: Lumpectomy, lymph node removal, cholecystectomy, ovarian cyst removed, abdominal hernia repair, and craniotomy for a brain tumor.
ALLERGIES: NKDA.
MEDICATIONS: Digitek, lisinopril, Levoxyl, Glucotrol, allopurinol, Arimidex, Lipitor, Natrecor drip, Lovenox, Protonix, and Lasix 40 mg p.o. daily.
SOCIAL HISTORY: The patient denies the use of alcohol and illicit drug use. She does have a history of tobacco abuse for 20 years, a pack and half of cigarettes per day. She quit 10 years ago.
FAMILY HISTORY: Father deceased at 70 years of age with history of congestive heart failure.
REVIEW OF SYSTEMS: Negative for blurred vision and headache. Negative for chest pain. Positive for dyspnea. Positive for palpitations. Negative for syncope. Positive for lightheadedness and dizziness prior to admission. Negative for nausea, vomiting, and diaphoresis. Negative for abdominal pain, GI bleed, and hematuria. Negative for DVT and PE. Negative for CVA and TIA. Negative for liver disease. Positive for thyroid disease. History of renal insufficiency. Negative for fever, chills, and edema.
PHYSICAL EXAMINATION:
VITAL SIGNS: Temperature 98.6 respirations 26, pulse 80, and blood pressure 124/74.
GENERAL: This is a well-nourished female, in no apparent distress. The patient is alert and oriented to person, place, and time. The patient is on O2 at 2 liters per nasal cannula.
HEENT: PERRLA. Normocephalic.
NECK: No thyromegaly. No carotid bruits. No JVD.
HEART: Regular rate and rhythm. Normal S1 and S2. No S3 or S4. A 2 to 3/6 grade systolic ejection murmur. No rubs. No clicks.
LUNGS: Bibasilar crackles.
ABDOMEN: Soft, nontender with positive bowel sounds in all four quadrants.
EXTREMITIES: Has 2+ pitting edema, bilateral ankles. 1 to 2+ dorsalis pedis pulses noted bilaterally.
LABORATORY DATA: White count 5.2, hemoglobin 12.6, hematocrit 38.4, platelets 136. Sodium 142, potassium 4.2, chloride 96, glucose 118, BUN 26, creatinine 1.2. ALT 13, AST 16.
EKG: Ventricularly paced.
IMPRESSION:
1. Congestive heart failure exacerbation, dyspnea on exertion. History of dilated cardiomyopathy with ejection fraction of 25% to 30% and New York Heart Association Class III symptoms. Status post BiV ICD.
2. History of moderate to severe mitral regurgitation and aortic incompetence.
3. Elevated D-dimer, rule out pulmonary embolism.
4. History of paroxysmal atrial fibrillation, now V-paced.
5. Hypertension.
6. Dyslipidemia.
PLAN:
1. Medtronic has checked the device. Results are in the chart.
2. We will review 2-D echocardiogram.
3. Continue Natrecor drip, ACE inhibitor, digoxin, Lipitor, and Lasix.
4. V/Q scan has been ordered to rule out pulmonary embolism.
Thank you for this consult. We will follow along with you.
