DATE OF CONSULTATION: MM/DD/YYYY
REFERRING PHYSICIAN: John Doe, MD
REASON FOR CONSULTATION: Abnormal EKG and history of coronary artery disease.
HISTORY OF PRESENT ILLNESS: The patient is a pleasant (XX)-year-old Hispanic female who has multiple coronary risk factors and known history of coronary artery disease and had undergone a five-vessel bypass about three years ago. The patient also had a small myocardial infarction prior to that. She was in her usual state of health until about three or four days ago when she started having generalized weakness, feeling dizzy and lightheaded, and easy fatigability.
She had a couple of brief episodes of localized left inframammary chest discomfort, which was lasting for a few minutes. This was not exertional in nature, and this was not pleuritic. There was no radiation and no associated symptoms of shortness of breath, diaphoresis, nausea, vomiting or palpitation. She has not had any nocturnal symptoms. She denied any abdominal pain.
She came to the ER today at 9:30 a.m., and her blood pressure was 156/82, pulse rate 82 per minute. She was afebrile. Respiratory rate was 22 per minute. Pulse oximetry 96%. She was found to be severely anemic and has been admitted to PCU for further evaluation.
Her EKG had abnormalities, and therefore, we have been consulted. Currently, she denies any chest pain. She just feels generally weak.
PAST MEDICAL HISTORY: Hypertension, hyperlipidemia, diabetes mellitus, coronary artery disease status post MI, status post five-vessel CABG. No history of CVA, TIA or thyroid disorder.
PAST SURGICAL HISTORY: CABG about three years ago, hysterectomy, and right kidney surgery.
MEDICATIONS AT HOME: Glucovance, Cozaar 100 mg daily, diltiazem 240 mg daily, Plavix 75 mg daily, and aspirin daily.
ALLERGIES: MULTIPLE DRUG ALLERGIES. SEE CHART.
FAMILY HISTORY: Noncontributory.
SOCIAL HISTORY: She is married. She is currently not working. She denies any smoking, alcohol or drug abuse.
REVIEW OF SYSTEMS: As mentioned above. Otherwise, no fever, chills, rigors or cough. No sore throat or runny nose. No visual blurring or seizure. No abdominal or genitourinary complaints. No focal weakness of any extremities. She does have diabetic neuropathy with paresthesias of the lower extremities.
PHYSICAL EXAMINATION:
VITAL SIGNS: Blood pressure 152/86, heart rate 72 per minute, respiratory 18 per minute.
HEENT: Pupils are equally round and reactive to light and accommodation. EOMs intact. Sclerae are anicteric. There is no oropharyngeal congestion.
NECK: Supple. There is no JVD. Bilateral carotids are 2+ with no bruits. No thyromegaly or lymphadenopathy.
LUNGS: Clear to auscultation and percussion.
HEART: S1 and S2 normal. There is no S3, S4, murmurs, rubs, or gallops. Apical impulse is nondisplaced.
CHEST: There is a well-healed scar from a sternotomy.
ABDOMEN: Soft, nontender with no organomegaly. Bowel sounds are present and normal. No pulsatile masses or bruits.
EXTREMITIES: No pedal edema, cyanosis, or clubbing. The bilateral distal pulses are 2+ and symmetric.
NEUROLOGICAL: Grossly nonfocal, motor wise.
LABORATORY DATA: White count 10.8, hemoglobin and hematocrit 7.6 and 22.8, and platelet count 184,000. Protime was 13.2, INR of 1 and APTT 23.4. Sodium 141, potassium 4.8, chloride 108, bicarbonate 24, glucose 132, BUN and creatinine 52 and 1.2, calcium 9.6. CPK 32 and CPK-MB 3.5. Troponin I negative. Urinalysis showed 5 to 10 wbc’s.
EKG done this morning showed normal sinus rhythm with rate 82 per minute. There are diffuse nonspecific ST-T abnormalities, early transition in precordial leads. As compared to prior EKG, ST-T abnormalities are slightly more prominent.
IMPRESSION:
1. This is a (XX)-year-old female with multiple coronary risk factors and known history of coronary artery disease and prior surgical revascularization, who is presenting with severe blood loss anemia secondary to upper gastrointestinal bleed. She is currently hemodynamically stable. It is possible that she may have a bleeding peptic ulcer, and she may have had upper gastrointestinal bleed.
2. Abnormal EKG with nonspecific ST-T abnormalities, which are slightly more prominent than last year. We cannot exclude ischemia, and in view of her history of coronary artery disease and in the presence of severe anemia, which may have precipitated ischemia, she is currently not having any chest pain. She did have some atypical chest pain four or five days ago. Currently, there is no evidence of any decompensated congestive heart failure.
3. History of hypertension.
4. Diabetes mellitus with diabetic neuropathy.
5. History of hyperlipidemia, but currently not on any therapy.
6. Urinary tract infection.
RECOMMENDATIONS:
1. Agree with continuing monitoring on telemetry.
2. Transfuse packed red cells and maintain hemoglobin and hematocrit at around 10 and 30.
3. Would also stop aspirin and Plavix.
4. Agree with proton pump inhibitors.
5. Monitor hemoglobin and hematocrit closely.
6. We will check a fasting lipid profile for risk stratification.
7. We will obtain an echocardiogram to evaluate LV function and assess regional wall motion abnormality.
8. We will obtain serial cardiac enzymes.
9. We will hold diltiazem but will continue Cozaar at lower dose at 50 mg daily, in view of the fact that because of her bleeding, it is possible that she may get hypotensive. Monitor her vital signs closely.
10. Recommend a GI consult.
11. Further recommendations to follow.
Thank you, Dr. Doe, for allowing us to participate in the care of this nice lady.
