DATE OF CONSULTATION: MM/DD/YYYY
REFERRING PHYSICIAN: John Doe, MD
REASON FOR CONSULTATION: Electrophysiologic evaluation.
HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old gentleman who is known to have coronary artery disease and underwent coronary artery bypass grafting. He has ischemic cardiomyopathy, and the ejection fraction is about 30%. He has multiple cardiac risk factors, including diabetes mellitus, hypertension, and dyslipidemia. Apparently, the patient at home felt dizzy and passed out. He is not really very sure about the duration of loss of consciousness. He has had injury to the left knee and also the left hip when he fell. Within the episode, he had had no palpitations, chest pain or shortness of breath. He has had no documented cardiac arrhythmia. He denies having had any prior history of congestive heart failure. He apparently had workup by Dr. Jane Doe recently. It appears that he had had stent placement. Again, details are not really very clear.
PAST MEDICAL HISTORY: Significant for diabetes mellitus, hypertension, dyslipidemia, and gastroesophageal reflux disease. Recent nuclear stress testing did not reveal any ischemia.
PAST SURGICAL HISTORY: Significant for bypass surgery, cataract surgery, cholecystectomy, hernia repair, and prostate surgery for prostate cancer.
ALLERGIES: NKDA.
MEDICATIONS ON ADMISSION: Reviewed. He is on Nexium 40 once a day, Coreg 3.125 b.i.d., Plavix 75 once a day, lovastatin 40 mg daily, digoxin 0.25 mg once a day, lisinopril 40 daily, aspirin, glipizide, Os-Cal, and Metamucil.
SOCIAL HISTORY: The patient does not smoke. He drinks alcohol occasionally.
FAMILY HISTORY: Negative for premature coronary artery disease.
REVIEW OF SYSTEMS: Essentially unremarkable.
PHYSICAL EXAMINATION:
GENERAL: This is a patient who seems to be in no apparent distress. He is afebrile.
VITAL SIGNS: Heart rate 62. Blood pressure 126/52.
HEENT: Unremarkable.
NECK: Supple. There is no jugular venous distention. No thyromegaly or lymphadenopathy.
HEART: Normal heart tones with regular rate and rhythm.
CHEST: Clear to percussion and auscultation.
ABDOMEN: Soft, nontender, and normoactive bowel sounds.
EXTREMITIES: Revealed no cyanosis, clubbing or edema.
CENTRAL NERVOUS SYSTEM: Examination appeared to be grossly intact.
DIAGNOSTIC DATA: EKG revealed normal sinus rhythm with an old anterior wall infarction. He had nonspecific T-wave abnormality. Chest x-ray revealed cardiomegaly, mild right lower lobe atelectasis and/or infiltrate. Lumbar spine x-ray revealed mild lumbar spondylosis and surgical change in the right upper quadrant suggesting cholecystectomy.
LABORATORY DATA: White cell count 8.6, hemoglobin of 13.4, hematocrit 40.2, and platelet count of 174,000. INR is 1.02. D-dimer 0.24. Electrolytes showed potassium of 3.9, BUN 18, creatinine 1.0, calcium 9.6. LFT is normal. Digoxin level was 0.8, which is therapeutic. Urinalysis was unremarkable.
IMPRESSION: This is an elderly gentleman who was admitted following questionable syncopal episode. He has been feeling dizzy and has been falling. He has ischemic cardiomyopathy and is status post coronary artery bypass grafting.
PLAN: Given the history of bypass surgery and cardiomyopathy, he will require electrophysiological study for evaluation of inducible arrhythmia. If ejection fraction is less than 30%, then he will qualify for a prophylactic defibrillator. If ejection fraction is more than 30 and unless EP study shows inducible arrhythmia, he will not need the device. We will arrange for an EP study to be done early next week.
