DATE OF CONSULTATION: MM/DD/YYYY
REFERRING PHYSICIAN: John Doe, MD
REASON FOR CONSULTATION: Surgical risk stratification preoperatively.
HISTORY OF PRESENT ILLNESS: This is a (XX)-year-old female with a history of essential hypertension and paroxysmal atrial fibrillation. She is not followed by a cardiologist as an outpatient. The patient states she was previously seen on hospitalization; however, did not go back to follow up. Per record, she was last seen during the previous hospitalization. At that time, the patient had Myoview stress testing performed, which revealed a normal perfusion, normal wall motion, and ejection fraction of 57%. She also subsequently had an echocardiogram at that time, which showed mild left ventricular dysfunction; however, no percentage noted, posterobasal hypokinesis, aortic valvular sclerosis without stenosis, trace tricuspid regurgitation with evidence of some mild diastolic dysfunction. The patient presented to hospital after an accidental fall in her apartment. She slipped on the kitchen floor and suffered a comminuted/spiral femoral fracture. The patient is scheduled to undergo repair today. We were asked to evaluate given her past cardiac history. The patient denies any chest pain or recent bouts of chest pain. She denies any shortness of breath. No recent lightheaded spells or syncopal events. Coumadin has been discussed with the patient as she was admitted with an INR of 1.02. The patient is supposed, per medication list, to be taking Coumadin. The patient does not recall whether she has been taking it or not. Again, as noted above, she has failed to follow up with the cardiologist.
PAST MEDICAL HISTORY: As noted below.
PAST SURGICAL HISTORY: Significant for bilateral total knee arthroplasties and tonsillectomy.
FAMILY HISTORY: Sister had a myocardial infarction at the age of 55. Father had a myocardial infarction at age of 79.
MEDICATIONS AT HOME: Hydrochlorothiazide 25 mg daily, Cardizem 120 mg p.o. daily, Xanax 1 mg p.o. daily, aspirin 81 mg daily, and Coumadin, unknown dose.
ALLERGIES: SULFA.
SOCIAL HISTORY: The patient lives alone in her apartment. She has a past history of tobacco abuse, but she has quit. She has an approximate 30- to 40-pack-year-history of tobacco use. She denies any history of excess alcohol use or illicit injection drug use.
REVIEW OF SYSTEMS: Pertinent review of systems as noted above. Otherwise, 14-point review of systems negative or noncontributory.
PHYSICAL EXAMINATION:
GENERAL: This is a (XX)-year-old female who is awake and alert. She answers questions appropriately.
VITAL SIGNS: Blood pressure is 118/72, pulse is 76, respiratory rate 20, saturating 92% on room air. The patient is afebrile.
HEENT: Head is normocephalic and atraumatic. Extraocular movements are intact.
NECK: Supple. There is no lymphadenopathy or thyromegaly. There is no jugular venous distention at about 35-40 degrees.
LUNGS: Breath sounds are clear bilaterally.
HEART: Irregularly irregular. There are no appreciable murmurs, rubs or gallops. There are no visible or palpable precordial thrills or heaves.
ABDOMEN: Soft, nontender, and nondistended. There are audible bowel sounds. There are no palpable masses.
EXTREMITIES: Warm without edema.
PERIPHERAL VASCULAR: Carotids and pedal pulses are palpable. There are no auscultable carotid bruits.
LABORATORY DATA: WBC is 9.2, H&H is 16.4 and 49.4, and platelet count is 296,000. INR is 1.02. Sodium 138, potassium 3.8, BUN is 12, creatinine is 0.8, and magnesium is 2.
RADIOLOGIC STUDIES: EKG shows atrial fibrillation at 72 beats per minute. There is a left axis deviation. There are diffuse nonspecific T-wave inversions with minimal ST change diffusely. When compared to the prior EKGs, there are minimal ST changes as well; however, anterolateral T-wave changes appear to be new.
IMPRESSION:
1. Comminuted/spiral femoral fracture secondary to accidental fall.
2. History of paroxysmal atrial fibrillation, currently controlled ventricular response. Subtherapeutic INR on admission given the patient’s noncompliance with medication.
3. Essential hypertension, controlled.
4. No history of coronary artery disease.
a. Adenosine Myoview done last year shows no ischemia and no wall motion abnormalities with an ejection fraction of 57%.
b. Echocardiogram done last year shows mildly reduced ejection fraction, questionable diastolic dysfunction, and aortic valve sclerosis.
RECOMMENDATIONS: There is no absolute contraindication to proceeding with surgery, as the patient is without any anginal symptoms and is euvolemic at the present time. The patient is, however, an intermediate cardiac risk. She will need perioperative beta-blockers, telemetry, and postoperative EKG as well as Lovenox. We have discussed with the patient at length the risks of CVA, both on and off anticoagulation as well as need for medication compliance and for cardiac followup. We will follow along postoperatively.
