DATE OF CONSULTATION: MM/DD/YYYY
REFERRING PHYSICIAN: John Doe, MD
REASON FOR CONSULTATION: Near syncope, near drowning.
HISTORY OF PRESENT ILLNESS: This is a (XX)-year-old gentleman who apparently had an episode of near drowning four days ago, preceded by a near syncopal episode causing him to fall into water. He was in the intensive care unit on a ventilator for some time before he extubated himself. He has done reasonably well since that time; however, evaluation was requested given the patient’s abnormal stress test. The patient had an episode of near syncope a month to two months ago. A stress nuclear study was subsequently performed, and this revealed ischemia in the territory of the right coronary artery. The patient has denied any chest pain in the past and denies shortness of breath in the past as well. Currently, he denies any chest pain.
PAST MEDICAL HISTORY: History of a stroke with a left lacunar infarction in the past, dementia, and benign prostatic hypertrophy.
CURRENT MEDICATIONS: Valium, Exelon, calcium, aspirin, Fosamax, and Remeron.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: Negative for active tobacco use.
FAMILY HISTORY: Noncontributory.
REVIEW OF SYSTEMS: An adequate review of systems is unable to be obtained from the patient given the language barrier. He does, however, deny any chest pain or shortness of breath at rest.
PHYSICAL EXAMINATION:
VITAL SIGNS: Temperature 97.8, pulse 82, blood pressure 130/74, respiratory rate 20, and O2 saturation 95%.
GENERAL APPEARANCE: This is an alert, elderly male in no acute distress.
HEENT: Unremarkable.
NECK: Normal carotid upstrokes bilaterally. There are no carotid bruits. There is no jugular venous distention.
HEART: Regular rhythm without any murmurs or gallops.
LUNGS: Diffuse crackles as well as rhonchi in all lung fields.
ABDOMEN: Soft and nontender to palpation.
EXTREMITIES: Warm without any edema. Essentially normal strength in all extremities.
NEUROLOGIC: The patient is alert and oriented.
SKIN: Negative for tattoos, rashes or ulcers in the feet.
SPINE: There is no kyphoscoliosis.
LABORATORY AND DIAGNOSTIC DATA: Sodium 142, potassium 3.5, chloride 108, carbon dioxide 24, BUN 12, creatinine 0.9, magnesium 1.8, calcium 7.8 with an albumin of 2.6. Hemoglobin 11.4, white count 11.4, and platelet count is 142,000. AST is 84 and ALT is 52. CT of the head revealed an old focal lacunar infarction in the left side. CT of the chest revealed patchy alveolar densities throughout the lungs. Nuclear stress test performed in our office revealed mild to moderately abnormal stress perfusion study with ischemia in the probable territory of the right coronary artery. The ejection fraction was 62%. These findings were new when compared to a prior study performed a year and a half ago.
IMPRESSION:
1. Near drowning.
2. Abnormal nuclear stress test with ischemia in the territory of the right coronary artery.
3. Near syncope with a recurrent episode.
4. History of a stroke.
RECOMMENDATIONS: An echocardiogram was apparently done at the outside hospital, which revealed normal ejection fraction, no wall motion abnormalities, and normal valve structure. Etiology for near syncope then could be secondary to an arrhythmia, potentially due to coronary artery disease given the abnormal nuclear stress test. We believe a cardiac catheterization would be the best approach; however, we would want to wait until improvement in the patient’s lung exam is noted. A lipid profile will need to be obtained.
