DATE OF CONSULTATION: MM/DD/YYYY
REASON FOR CONSULTATION: Abnormal electrocardiogram.
HISTORY OF PRESENT ILLNESS: We were asked by Dr. John Doe to consult regarding evaluation and management of inferior and anterior lead ST segment elevation discovered today on cardiac monitor. The ST segment elevation was confirmed on the electrocardiogram. The patient is a (XX)-year-old Hispanic woman who was admitted for management of pyelonephritis and sepsis. Her history is otherwise notable for insulin-dependent diabetes. She is visiting from another city and began to experience nausea, vomiting, and left flank pain. In the emergency department, she was found to be profoundly thrombocytopenic and was admitted.
The nurses noted ST segment changes on the cardiac monitor, and an electrocardiogram confirmed ST segment elevation. The patient denies any history of chest discomfort. She is currently not short of breath. She denies a known history of coronary artery disease or hyperlipidemia.
MEDICATIONS: Insulin, dose unknown. As an inpatient, she is taking Ancef 1 g IV q. 8 h., Colace 250 mg at bedtime, Pepcid 20 mg IV q. 24 hours, insulin, metoprolol 25 mg b.i.d., nitroglycerin 1 inch q. 6 h., and senna 2 tabs p.o. q.a.m.
ALLERGIES: None known.
SOCIAL HISTORY: The patient is currently not married. She does have one son. She does not smoke cigarettes or drink alcohol.
FAMILY HISTORY: The patient’s mother had diabetes, but there is no known family history of premature myocardial infarction or hypertension.
REVIEW OF SYSTEMS: Notable for fatigue, weakness and nausea. Her chills and diarrhea have resolved. She denies bruising. See the history of present illness. A 14-point review of systems was negative otherwise.
PHYSICAL EXAMINATION:
GENERAL APPEARANCE: The patient is somewhat somnolent but arousable and responsive.
VITAL SIGNS: Temperature is 37.2, blood pressure 128/78, pulse 76, respiratory rate 26, SpO2 100% on 5 liters. Weight 150 pounds.
HEENT: Pupils are round and reactive to light and accommodation. The oropharynx is clear. Petechiae are present on the soft palate.
NECK: The thyroid is not enlarged. There is no cervical adenopathy. Carotid upstrokes are 1+.
LUNGS: Clear to auscultation. Percussion was not performed.
HEART: There is a regular rhythm with normal first and second heart sounds. There is no significant murmur, third or fourth heart sound.
ABDOMEN: Soft. Bowel sounds are present. There is no tenderness. There is no hepatosplenomegaly.
EXTREMITIES: There is no cyanosis, clubbing or edema. Posterior tibial pulses are trace.
SKIN: No rash or ecchymosis.
NEUROLOGIC: Grossly intact. She moves all four extremities.
LABORATORY DATA: WBC 9.6, hemoglobin 7.2, hematocrit 21.8, platelets 58. Troponin T performed on day of admission was 1.06, decreasing next day to 0.94 and then 0.814. Serial CK-MB measurements beginning day of admission was 71.6, decreasing next day to 41.4 and then to 23.2.
Glucose 132, sodium 128, potassium 3.6, chloride 98, creatinine 1.1, alk phos 198, ALT 16, AST 56, total bili 3.7, and INR 1.2.
DIAGNOSTIC DATA: Electrocardiogram performed on day of admission revealed a sinus tachycardia with a rate of 108. This tracing is otherwise within normal limits. Electrocardiogram performed a couple of days later revealed inferior lead ST segment elevation and anteroseptal ST segment elevation. The electrocardiogram performed yesterday revealed a normal sinus rhythm with nonspecific ST and T wave changes. ST segment elevation was no longer present in the inferior or anterior leads.
Chest x-ray performed yesterday revealed bilateral pleural effusions and bibasilar atelectasis/consolidation. There was stable pulmonary vascular congestion.
IMPRESSION:
1. Abnormal electrocardiogram with inferior and anterior lead ST segment elevation yesterday associated with declining cardiac enzymes. The cardiac echo performed today demonstrates distal septal and inferoapical hypokinesis. She has suffered an ischemic event, which may be due to coronary artery disease secondary to diabetes. Another possibility is that this is a mild version of Takotsubo cardiomyopathy. The patient has no history of exertion-related chest discomfort, and at the time of her ST segment elevation, no chest discomfort was reported. An ischemic evaluation is indicated.
2. Pyelonephritis, improving with antibiotics.
3. Anemia and thrombocytopenia.
RECOMMENDATIONS: Aspirin 81 mg would ordinarily be prescribed in the setting of an acute coronary syndrome, but with platelets of 57,000, aspirin will be held for the moment. We concur with medical therapy with metoprolol and nitroglycerin. The metoprolol dose will be increased to 50 mg b.i.d. A lipid panel will be performed and atorvastatin added. The insulin-dependent diabetes gives her a high risk for coronary artery disease. She likely has significant hyperlipidemia. A Lexiscan will be performed in the morning to rule out important reversible ischemia.
