DATE OF CONSULTATION: MM/DD/YYYY
REFERRING PHYSICIAN: John Doe, MD
REASON FOR CONSULTATION: Surgical evaluation for coronary artery disease.
HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old gentleman who suffered a myocardial infarction eight years ago. At that time, he was found to have occlusion to the right coronary artery system. Apparently, PTCA and stent was placed. He has been otherwise stable with medical management with no recurrent angina. A nuclear stress test was abnormal showing a defect in the inferior wall. For this reason, he was admitted for purposes of a cardiac catheterization. This revealed a 50% stenosis by IVUS to the left main coronary artery. There was also a 60-70% stenosis to the left anterior descending artery. The stented area to the right coronary artery system is patent with only some mild luminal irregularities. Overall, his left ventricular function remains good with an ejection fraction of at least 50%. In view of these findings, surgical consultation was requested.
PAST MEDICAL HISTORY: Coronary artery disease as described above and previous sinus surgery.
ALLERGIES: None.
MEDICATIONS: Enalapril 5 mg twice a day, metoprolol 25 mg twice a day, Plavix 75 mg daily, aspirin 81 mg daily, and Lipitor 40 mg daily.
SOCIAL HISTORY: The patient quit smoking over 20 years ago. Prior to that time, he had about a 20-pack-year history. He uses alcohol in moderation. He is divorced and has remained very active.
FAMILY MEDICAL HISTORY: Significant for premature coronary artery disease but not diabetes mellitus.
REVIEW OF SYSTEMS: The patient admits to chronic headaches. The patient did suffer myocardial infarction in the past. At that time, he underwent a PTCA and stenting procedure to the right coronary artery system.
PHYSICAL EXAMINATION:
VITAL SIGNS: Blood pressure is 132/82 mmHg, pulse 82 beats per minute and regular, respirations 18 breaths per minute and unlabored, and temperature 97.6 degrees Fahrenheit.
GENERAL: This is a middle-aged, pleasant-appearing gentleman, currently not in acute distress.
HEENT: Pupils are equal and reactive to light. Conjunctivae clear. Throat is benign. Mucosa is moist and noncyanotic.
NECK: Neck veins are nondistended at 90 degrees. Carotids have 2+ upstrokes bilaterally without bruits. No lymphadenopathy is appreciated.
CHEST: Chest has a normal AP diameter.
LUNGS: Clear in apices and bases. No wheezing or rubs appreciated.
HEART: Normal S1, S2, without murmurs, clicks or gallops.
ABDOMEN: Soft, nontender, and nondistended. Good bowel sounds present. No organomegaly is appreciated. No pulsatile masses are felt. No abdominal bruits are heard.
EXTREMITIES: Pulses 2+ and equal bilaterally in the upper and lower extremities. No clubbing is appreciated.
NEUROLOGIC: He is oriented x3. He demonstrated good bilateral strength in the upper and lower extremities. Face is symmetrical with normal gait.
IMPRESSION AND PLAN: The patient is a (XX)-year-old gentleman with left main disease of about 50%. The patient is asymptomatic and has been on Plavix. He is at risk for an ischemic event. In order to reduce his risk, surgical myocardial revascularization should be pursued. However, he is asymptomatic and feels that he should come off of Plavix for at least 3 to 4 days prior to any surgical intervention in order to minimize his risk for bleeding. We felt that since he is asymptomatic, it would be reasonable for him to go home with plans for him to return to our office in 3 days, and at that time, we can discuss the timing in regards to surgery. All additional questions were answered.
