DATE OF CONSULTATION: MM/DD/YYYY
REFERRING PHYSICIAN: John Doe, MD
REASON FOR CONSULTATION: The patient is a (XX)-year-old female with history of COPD, myelodysplastic syndrome, transfusion dependent, who presented with left-sided chest pain and was admitted for further evaluation.
SOURCE OF INFORMATION: The patient is a poor historian, and history is obtained from nursing staff and previous medical record.
HISTORY OF PRESENT ILLNESS: The patient is a very pleasant (XX)-year-old Hispanic female with multiple comorbidities, including myelodysplastic syndrome resulting for pancytopenia and she is transfusion dependent. She has a history of GI bleeding secondary to AV malformation and history of hypertension for which she is taking multiple medications. She has a history of coronary artery disease, history of abdominal aortic aneurysm; she is status post repair. She has a history of intracranial hemorrhage in the past.
The patient was discharged from the hospital last week after being treated for fluid overload and congestive heart failure. During that time, the patient was treated with diuretics. Today, the patient came for regular blood transfusion, and after blood transfusion, she started to complain of left-sided chest pain and was admitted for further evaluation. Currently, the patient is complaining of chest pain and sharp tenderness localized to the left anterior chest wall. She denies any increasing shortness of breath. She denies any increasing cough, orthopnea or paroxysmal nocturnal dyspnea.
PAST MEDICAL HISTORY: As stated above, includes myelodysplastic syndrome, transfusion dependence, COPD, hypertension, gout, history of GI bleeding secondary to AV malformation, history of intracranial hemorrhage, history of renal insufficiency, history of coronary artery disease, and congestive heart failure. She is status post abdominal aortic aneurysm repair.
MEDICATIONS: List reviewed.
ALLERGIES: PENICILLIN.
FAMILY HISTORY: Noncontributory.
SOCIAL HISTORY: The patient smokes once in a while. Otherwise, she denies any use of alcohol.
REVIEW OF SYSTEMS: The patient is not a good historian. She denies any increasing shortness of breath, but she coughs once in a while. No orthopnea or paroxysmal nocturnal dyspnea. She is having chest pain as stated in the history of present illness.
PHYSICAL EXAMINATION:
GENERAL: The patient is an elderly lady, in distress secondary to pain localized to the left chest wall. Otherwise, not in cardiorespiratory distress.
VITAL SIGNS: Blood pressure 190/92, pulse rate 82 per minute, respiratory rate 20 per minute, saturating 97% on 2 liters, and temperature 99.2 degrees.
HEENT: Head is atraumatic. Pupils are equal and reactive bilaterally. Pink conjunctivae. Anicteric sclerae. Oropharyngeal examination significant for slight crowding.
NECK: Short.
CHEST: Symmetrical chest expansion. She had some rhonchi, mostly on the right side. She has localized tenderness over the sternum and the left anterior chest wall.
HEART: S1 and S2 are heard.
ABDOMEN: Obese but soft and nontender. No organomegaly.
EXTREMITIES: Did demonstrate edema bilaterally, pitting. No cyanosis or clubbing.
NEUROLOGIC: Alert and oriented x3. No focal deficit.
LABORATORY DATA: Pending.
DIAGNOSTIC DATA: Chest x-ray reviewed. There is no infiltrative process seen. The patient had a CAT scan of the chest done during last admission, which showed minimal effusion on the right side. She has some density localized to the left lower lobe, which was considered to be probable atelectasis. There was cardiomegaly suggested.
ASSESSMENT: The patient is a (XX)-year-old female with multiple comorbidities, including myelodysplastic syndrome, which is transfusion dependent, COPD, history of hypertension for which she has been on multiple medications, coronary artery disease, and congestive heart failure for which she was treated with aggressive diuresis during last admission. The patient now presented for blood transfusion and was admitted with left-sided chest pain. The chest pain seems to be musculoskeletal in origin, but we cannot rule out underlying ischemia. EKG done on presentation did not show any active ST-T change. Otherwise, she had history of chronic obstructive pulmonary disease, hypertension, gout, and prior history of gastrointestinal bleeding and intracranial hemorrhage. She had also history of renal insufficiency.
RECOMMENDATIONS:
1. Continue pain treatment with narcotic.
2. Blood pressure control.
3. Oxygen supplementation.
4. Bronchodilator therapy with DuoNeb.
5. Follow up with WBC and temperature. If she is going up, would start antibiotic therapy. Currently, chest x-ray does not show any significant infiltrate.
6. Would check cardiac enzymes and EKG. The patient would benefit from cardiology evaluation.
7. The patient would continue her regular home medication.
8. We will follow up closely and make appropriate recommendation based on clinical response. Overall, the patient’s prognosis is poor.
