DATE OF CONSULTATION: MM/DD/YYYY
REASON FOR CONSULTATION: Substernal chest burning.
HISTORY OF PRESENT ILLNESS: This is a (XX)-year-old male with known CAD, status post four angioplasties, with his last stent two years ago. The patient developed substernal chest pressure while walking the dog last night. The symptom lasted approximately 15 minutes. He did not have radiation of the symptoms. He did feel a little short of breath. The patient had resolution of these symptoms 15 minutes after nitroglycerin paste was placed on his chest. The patient has been pain-free. The patient states this is very similar to his prior angina in the past. The patient has had prior MI; the details are not known. He has had several angioplasties in the past, with his last one two years ago. The patient denies any history of heart failure or stroke. He does have hypertension with polycystic kidney disease, status post renal transplant 12 years ago. The patient denies diabetes. He generally takes Lipitor without complaints of myalgias. The patient stopped his aspirin for the last four days due to GI upset, which he has been having for the last three to four weeks. The patient has lost 10 to 15 pounds with some intermittent diarrhea, being evaluated by Dr. John Doe. The patient denies any accelerated palpitations or syncope. Otherwise, he has a negative cardiac review of systems.
PAST MEDICAL HISTORY:
1. Polycystic kidney disease, status post renal failure, status post renal transplant 12 years ago, on cyclosporine.
2. CAD, status post prior MI and multiple angioplasties, including the last stent placed two years ago.
3. Hypertension.
4. Dyslipoproteinemia.
5. History of hernia surgery.
6. Diverticulosis.
MEDICATIONS ON ADMISSION: Neoral; CellCept; prednisone 7.5 mg daily; Adalat 30 b.i.d.; Toprol 25 b.i.d.; Lipitor 10 daily; eyedrops for glaucoma; Prevacid 15 b.i.d.; aspirin 81 at bedtime, held for the last four days; vitamin E 400 a day; calcium; and Fosamax.
ALLERGIES: NKDA.
SOCIAL HISTORY: No tobacco, significant alcohol or drug use. The patient is married. The patient has one child.
FAMILY HISTORY: Mom had an MI in her 40s.
REVIEW OF SYSTEMS: As above. He does have occasional heartburn, otherwise all negative.
PHYSICAL EXAMINATION:
GENERAL: The patient is alert and oriented, in no apparent distress.
VITAL SIGNS: Blood pressure 142/82, pulse 72 and regular, respirations 18, afebrile.
HEENT: Eyes, no xanthelasma. ENT, unremarkable.
NECK: Normal JVD. Normal carotid upstrokes. No bruits.
LUNGS: Clear.
HEART: Normal on palpation, soft S4, 1/6 holosystolic murmur. No S3.
ABDOMEN: Somewhat bloated. No tenderness. No rebound. No pulsatile masses. No hepatosplenomegaly.
EXTREMITIES: No edema. Pulses are +2 and symmetric.
NEUROLOGIC: Grossly nonfocal.
NEUROPSYCHIATRIC: Appropriate.
MUSCULOSKELETAL: Limited exam.
SKIN: Unremarkable.
DIAGNOSTICS AND LABORATORY DATA: EKG, sinus bradycardia, probable old inferior wall myocardial infarction, age indeterminate, nonspecific ST changes from earlier this year. Anterior T wave abnormalities, improved compared to EKG done two years ago. Troponin negative x2. BUN 13, creatinine 0.8, potassium 4.2. LFTs within normal limits. CBC unremarkable. Chest x-ray was not available at the time of dictation. O2 saturation in the ER is within normal limits. Temperature in the ER was 97.2 degrees. Magnesium 1.5 in the emergency room. BNP 86 in the ER. PTT is within normal limits. Chest x-ray, no acute abnormality noted per ER report.
ASSESSMENT:
1. Chest pain, suggestive of prior angina.
2. Coronary artery disease with prior myocardial infarction and multiple stents.
3. Hypertension.
4. Dyslipoproteinemia.
5. History of polycystic kidney disease, status post renal transplant 12 years ago, on cyclosporine and prednisone.
6. Recent abdominal bloating and diarrhea, being evaluated by Dr. John Doe.
PLAN: We are concerned about the possibility of recurrent angina. Based on his symptoms and prior history, we would like to risk stratify him with an adenosine Cardiolite stress test. We discussed this with Nuclear Medicine and have held breakfast this morning; the patient had a small amount of decaffeinated tea which has been held at this point. Pending the results of the adenosine Cardiolite, Dr. Jane Doe will follow up with this patient. This has been discussed with Dr. Jane Doe.
