DATE OF CONSULTATION: MM/DD/YYYY
REFERRING PHYSICIAN: John Doe, MD
REASON FOR CONSULTATION: Abnormal cardiac enzymes and altered mental status.
HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old Hispanic female resident from a nursing home, who was brought into the emergency department yesterday because she had worsening mental changes. She was more inappropriate and confused at her place of residence, and she was noticed to be weaker than usual. She has a history of dementia, confusion, hip fracture, paroxysmal atrial fibrillation, possible stroke in the past, previous myocardial infarction, and previous open heart surgery with bypass approximately 15 years ago. She could not provide any details of her medical history. She is quite confused and does not know where she is and why she is here, or what year this is. The emergency department record makes a mention of left lower lobe pneumonia based on questionable infiltrate on the chest x-ray. The initial cardiac enzymes upon arrival showed an increased troponin and CK-MB consistent with an acute MI. The EKG in the emergency department yesterday has only a nonspecific tracing, but this morning has definitely ST elevations in the inferior-lateral leads suggestive of acute ST elevation MI. She is completely asymptomatic from the standpoint of chest pain. She denies shortness of breath; although, she is tachypneic.
PAST MEDICAL HISTORY: Consistent with previous hip fracture and paroxysmal atrial fibrillation.
CURRENT MEDICATIONS: Include nitroglycerin paste and aspirin. Probably in the nursing home, she is taking all other psychotropic drugs for dementia.
PHYSICAL EXAMINATION:
GENERAL: An elderly, frail, pale female in no acute distress but somewhat tachypneic.
VITAL SIGNS: Respiratory rate 22 per minute, blood pressure 102/62, heart rate 80, and saturation is 94% on 2 liters O2.
SKIN: The skin turgor is poor, consistent with dehydration.
LUNGS: Clear on auscultation anterior and laterally.
HEART: The heart is in sinus rhythm with a soft systolic and diastolic murmur.
EXTREMITIES: The extremity has 1+ edema. There are multiple ecchymotic areas and minor wounds. There is DJD present.
LABORATORY DATA: White count 17,800, platelets 160,000, and hemoglobin 12.4. INR 1.24. Sodium 138, potassium 3.9, glucose 102, and creatinine 1.0. CK-MB, the latest is 242 with total CK of 1474.
Chest x-ray shows early pulmonary edema.
IMPRESSION:
1. Acute ST elevation myocardial infarction in a very elderly, debilitated, bedridden, and demented patient. She is in mild congestive heart failure, in spite of dehydration.
2. Status post coronary artery bypass graft in the past, approximately 15 years ago.
3. Aortic and mitral valvular disease. No significant stenosis but significant regurgitation of both, by echo.
4. Advanced dementia.
5. Advanced age.
6. Very questionable community-acquired pneumonia. There is no fever. There is no cough. There is no sputum production. On infiltration of the chest x-ray, this may be related to early congestive heart failure instead. The white count is elevated. This could be related to myocardial necrosis; although, for complete exclusion of the diagnosis of pneumonia, further evaluation with subsequent x-rays and clinical followup is required.
RECOMMENDATIONS: Because of her underlying comorbidities including dementia, advanced age, previous bypass surgery, bedridden, previous hip fracture, falls, aortic valvular disease, and mitral valvular disease, this patient is not a candidate for acute intervention or invasive procedures. We will advocate just medical therapy and comfort care with conservative management of the myocardial infarction and heart failure. Obtain BMP, repeat chest x-ray and EKGs. Consider DNR.
