DATE OF CONSULTATION: MM/DD/YYYY
REFERRING PHYSICIAN: John Doe, MD
REASON FOR CONSULTATION: Preoperative cardiac clearance.
HISTORY OF PRESENT ILLNESS: This is an (XX)-year-old female who has a history of hypertension, on atenolol, postmenopausal, and history of osteoarthritis in the knees bilaterally, who presents for rectovaginal fistula surgical repair. Cardiology was consulted for preoperative clearance. The patient, approximately four years ago, did undergo a stress test and reports that as normal. We do not have those reports at this time. The patient denies any history of myocardial infarction, history of coronary artery disease, dyslipidemia, diabetes, or family history for premature coronary artery disease. The patient denies any history of tobacco use. The patient denies any history of exertional or rest chest pain. Denies shortness of breath, palpitations, orthopnea, paroxysmal nocturnal dyspnea, pedal edema, near syncope or syncope.
PAST MEDICAL HISTORY: As above.
PAST SURGICAL HISTORY: Plastic surgery, carpal tunnel release bilaterally.
SOCIAL HISTORY: The patient denies any history of tobacco or alcohol use.
FAMILY HISTORY: No evidence for premature coronary artery disease.
ALLERGIES: No known drug allergies.
MEDICATIONS: Atenolol 50 mg p.o. daily.
REVIEW OF SYSTEMS: As above, otherwise all 12 systems were reviewed and are negative.
PHYSICAL EXAMINATION:
GENERAL: This is a well-developed and well-nourished female, in no acute distress.
VITAL SIGNS: The patient is afebrile. Heart rate is 74, blood pressure 140/88, respirations are 18, and O2 saturation 97% on room air.
HEENT: Normocephalic and atraumatic with moist mucous membranes.
Neck: Supple with no JVD.
LUNGS: Clear to auscultation.
HEART: Revealed regular rate and rhythm with normal S1 and S2 and no murmurs, rubs or gallops were appreciated.
ABDOMEN: Positive bowel sounds, soft, nontender, and nondistended. No hepatosplenomegaly.
PERIPHERAL VASCULAR: Exam revealed 2+ carotid upstrokes and 2+ carotid, brachial, radial, femoral, popliteal, dorsalis pedis, and posterior tibialis pulses bilaterally. No carotid, abdominal or femoral bruits.
EXTREMITIES: Without cyanosis, clubbing or edema.
NEUROLOGIC: Grossly nonfocal.
LABORATORY DATA: CBC and CMP pending. Triglycerides 114, cholesterol 150, HDL 46, and LDL 82. Urinalysis reveals 2+ occult blood and 3+ leuk esterase.
DIAGNOSTIC DATA: Chest x-ray is pending. EKG reveals normal sinus rhythm at 72 beats per minute, normal axis and normal intervals. No ST-T wave changes.
IMPRESSION:
1. Rectovaginal fistula, awaiting surgical repair.
2. History of hypertension with moderate control.
RECOMMENDATIONS:
1. We will follow the results with a 2-D echocardiogram to evaluate left ventricular systolic function and rule out structural heart disease.
2. The patient will be scheduled for adenosine dual-isotope perfusion stress test today to rule out occult coronary artery disease.
3. Will increase atenolol to 50 mg p.o. b.i.d. as beta-blocker therapy has been shown to decrease the risk of cardiac complications perioperatively.
4. If the above procedures reveal no significant abnormalities, the patient will be considered low risk for perioperative cardiac complications.
5. We will continue to follow this patient with you.
Thank you very much for allowing us to participate in the care of this pleasant female.
