INDICATION FOR CARDIOLOGY CONSULT:
HISTORY OF PRESENT ILLNESS: this is a 66 year old hispanic male who was admitted after having an episode of
sudden onset shortnerss of breath with some mild substernal chest pain. Patient states that yesterday afternoon he
suddenly began to have some shortness of breath. He used his nebulizer treatment without any success. Because of
shortness of breath continued, he called the paramedics. He also describes some very mild substernal chest pain,
approximately 2/10 in intensity, which lasted for 10 to 15 minutes. He denies any orthopnea, PND, palpitations, or leg
edema. His CXR on admission does show some mild congestive heart failure. This patient has known ischemic CMP,
ejection fraction of approximately 30%.
This patient is well known to me as my cardiology outpatient. He has known CAD with prior MI. He has ischemic CMP.
He has had previous CABG in March 2011. A recent cardiac catheterization in january 2012 did show two occluded
grafts. He then underwent a LM stenting which was completed successfully. He is currently on ASA as well as
clopidogrel. He does have a history of paroxysmal atrial fibrillation and is also taking twice a day Pradaxa. He states he
is taking all his medications as prescribed. He is supposed to be on Advair; however, he has told Dr ... that he does not
have any inhalers at home at this time. His ECG shows atrial sensed ventricular paced rhythm. He does have an
underlying ICD for primary prevention.
PAST MEDICAL HISTORY:
PAST SURGICAL HISTORY:
ALLERGIES:
CURRENT MEDICATIONS:
SOCIAL HISTORY: the patient currently lives with his wife. He is an ex-tobacco smoker. He quit smoking 20 years ago,
but did smoke for 20 to 30 years. He smoked half a pack to one pack a day at that time. He is an immigrant from
Puerto Rico. He speaks semi-fluent english. He denies any tobacco or alcohol abuse.
FAMILY HISTORY: Non contributory for premature CAD, sudden cardiac death or congestive heart failure. He does
have a family history of diabetes and hypertension.
REVIEW OF SYSTEMS: Complete review of systems is obtained from patient, is negative except for what is stated in
history of present illness.
LABORATORY EXAMINATION:
ECG:
ECHO:
CATH:
TELE:
PHYSICAL EXAMINATION:
General: this is a well appearing elderly male who has no complaints of chest pain or shortness of breath since
admission.
Vital signs: Temperature, pulse, respirations, BP, O2 saturation % on RA.
HEENT: Head: normocephalic and atraumatic cranium. Buccal mucosa moist. No buccal edema. Dentition intact. Eyes:
pupils reactive to light and accomodation. EOM intact. Conjunctivae pink. Sclerae nonicteric.
neck: There is no JVD. No carotid bruits. No thyromegaly. No LADP. Trachea is midline.
Lungs: CTA bilaterally. Good inspiratory and expiratory effort. No wheezes, rhonchi or rales appreciated at this time.
Cardiac: regular rhythm. Normal rate. S1 and S2 auscultated. There is a 2/6 holosystolic murmur at the left and right
upper sternal border. no heaves, thrills, or rubs noted. Apical impulse is displaced left laterally.
Abdomen: obese. Positive BS. no guarding, rebound or tenderness to palpation. No hepatomegaly or ascites.
Extremities: no peripheral edema, clubbing or cyanosis. Patient has full range of motion of upper and lower extremities
bilaterally. Dorsalis pedis and popliteal pulses are 2+ bilaterally
Skin: no rash or petechiae
Neurologic: the patient is oriented to time, person and place. Non focal neurologic exam.
IMPRESSION:
1-Shortness of breath, which has improved, secondary to mild CHF, exacerbated possibly by asthma, chronic
obstructive pulmonary disease, or bronchitis
2-ICM with episode of acute systolic heart failure on this admission, now improved.
3-CABG, history of CAD, recent LM stent placement
4-History of PAF, currently in atrial sensed VP rhythm
5-COPD
6-history of Hypothyroidism secondary to amiodarone
7-Diabetes and renal insufficiency
8-HTN adn HPL
PLAN:
1-The patient has now improved after receiving lasix IV for his CHF. His BNP level has also improved
2-I re-educated the patient on fluid restriction, daily weights, salt restriction as well as medication compliance. He does
understand and will try to comply
3-The patient will follow up with me as an outpatient
Thank you for allowing me to participate in this patient's care. please do not hesitate to contact me with any further
questions