DATE OF CONSULTATION: MM/DD/YYYY
REFERRING PHYSICIAN: John Doe, MD
REASON FOR CONSULTATION: Sick sinus syndrome.
HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old male with a history of sick sinus syndrome, history of nonsustained ventricular tachycardia, history of ventricular ectopy, advanced parkinsonism, history of CVA, dementia, history of hernia repair, abscess of right groin, history of cardiomyopathy with an EF of 35%, history of hospice care, DNR status, and history of hypertension. The patient presents with worsening right groin pain, which started around four days ago, history of right inguinal abscess and his comorbidities. The patient was thought not to be an appropriate candidate for a permanent pacemaker. Last admission was three weeks ago.
PAST MEDICAL HISTORY: As stated in the history of present illness.
ALLERGIES: DIGOXIN.
MEDICATIONS: Septra DS, Synthroid, Niferex, Lasix, aspirin, lisinopril, potassium, Sinemet, Mirapex, Senokot, Seroquel, Aricept, and Pravachol.
FAMILY HISTORY: Noncontributory.
REVIEW OF SYSTEMS: Unable to obtain.
PHYSICAL EXAMINATION:
VITAL SIGNS: Temperature 97.6 degrees, pulse 52, respirations 18, and blood pressure 128/54.
GENERAL: This is a well-nourished appearing female who is disoriented with tremors noted.
HEENT: Pupils are equal and reactive to light and accommodation. Normocephalic.
NECK: No thyromegaly. No carotid bruits. No JVD.
HEART: Regular rate and rhythm. Normal S1 and S2. No S3 or S4. No murmurs, rubs or clicks.
LUNGS: Clear to auscultation bilaterally.
ABDOMEN: Soft and nontender. Positive bowel sounds, upper quadrants. Right groin incision area, mild erythema noted.
EXTREMITIES: Lower extremity edema noted in the right lower extremity. Poor peripheral pulses noted bilaterally.
DIAGNOSTIC DATA: EKG: Sinus bradycardia, rate of 40, left bundle branch block.
LABORATORY DATA: Sodium 134, potassium 5, BUN 24, creatinine 1.4, glucose 106. White count 5.8, hemoglobin 10.6, hematocrit 31.4, and platelets 186,000.
IMPRESSION:
1. Sinus bradycardia with a history of sick sinus syndrome.
2. History of nonsustained ventricular tachycardia and ventricular ectopy in the past.
3. History of cerebrovascular accident.
4. History of dementia.
5. Advanced Parkinson’s disease.
6. History of right groin hernia repair with history of abscess of the right groin, now presents with right groin pain.
7. Cardiomyopathy, ejection fraction of 35%.
8. History of hospice. DNR status.
PLAN: We will continue with conservative management. No AV blocking agents.
