DATE OF CONSULTATION: MM/DD/YYYY
REFERRING PHYSICIAN: Jane Doe, MD
REASON FOR CONSULTATION: Atrial fibrillation.
HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old female with hypertension and hypercholesterolemia with no diabetes mellitus, who presented to the emergency department secondary to a mechanical fall. She had pain in her hips, running downward to her ankle. She has had chest pain intermittently for several months, up to a year. She was found in atrial fibrillation with a marked leukocytosis. X-rays revealed no fracture. CT of the head revealed no acute bleed; however, it did reveal an old infarct. The patient was placed on Cardizem drip upon arrival, which has now been discontinued, and the patient was switched over to Cardizem 30 mg p.o.
PAST MEDICAL HISTORY: Osteoporosis, osteoarthritis, peptic ulcer disease with GI bleed, urinary tract infection, and hypothyroidism.
FAMILY HISTORY: Daughter died at 60 of coronary artery disease; however, the patient states her husband had a history of coronary artery disease, and her family did not.
SOCIAL HISTORY: The patient denies smoking, rare alcohol intake.
MEDICATIONS: Cardizem 30 mg and normal saline at 50 mL an hour.
ALLERGIES: The patient has no known drug allergies.
REVIEW OF SYSTEMS:
GENERAL: The patient denies any significant alteration in weight, any fever or any chills.
HEENT: Denies any headaches, dizziness or alteration in vision.
RESPIRATORY: Denies any cough, hemoptysis or wheezing.
GASTROINTESTINAL: No nausea, vomiting, diarrhea, constipation or alteration in bowel habits. No melena and no hematemesis.
MUSCULOSKELETAL: Does have significant osteoporosis and osteoarthritis, which she states limits her ability to ambulate. Also see HPI.
NEUROLOGIC: The patient is alert and oriented with no focal or neurological deficits noted on inspection.
LABORATORY AND DIAGNOSTIC DATA: Troponin is at 1.74, BNP is 436. Head CT reveals an old infarct with no significant bleed. Sodium 132, potassium 3.6, BUN 16, and creatinine 1.0. TSH is pending. WBCs are 22.6, hemoglobin 12.2, hematocrit 35.8, and platelets are 214,000. EKG reveals atrial fibrillation with a rapid ventricular response with ST segment depression in V4 to V6.
IMPRESSION:
1. Atrial fibrillation with rapid ventricular response.
2. Elevated troponin, most likely a non-ST elevation myocardial infarction; however, this could also be due to the atrial fibrillation with a mismatch.
3. Leukocytosis.
4. Mechanical fall.
5. Sprain of the left ankle.
PLAN: The patient refuses any type of invasive cardiac workup at this time. In fact, the patient insistently wishes to be a DNR as well. Anticoagulation, Integrilin are being deferred immediately secondary to the recent fall with multiple contusions. We will further evaluate this and may start later, depending upon the remainder of the patient’s evaluation. The patient will need a 2D echocardiogram to evaluate the function of the heart, aspirin 81 mg, start the patient on digoxin, and give a 250 mL bolus of normal saline.
Thank you very much, Dr. Doe, for having allowed us to participate in this patient’s care.
