DATE OF CONSULTATION: MM/DD/YYYY
REASON FOR CONSULTATION: Preoperative cardiovascular risk assessment.
HISTORY OF PRESENT ILLNESS: We were asked by Dr. John Doe to consult regarding cardiovascular risk for dental surgery. The patient is a (XX)-year-old Hispanic woman admitted for oral surgery. She has significant right upper jaw pain. Drainage of an abscess is planned. The patient’s cardiovascular history is notable for longstanding hypertension and stroke. She has atrial fibrillation. There is no known history of coronary artery disease. She denies history of myocardial infarction.
PAST MEDICAL HISTORY: Notable for a history of respiratory failure and tracheostomy placement. She has diabetes, hyperlipidemia, and a depressive disorder. Her cardiovascular history is as noted above.
PAST SURGICAL HISTORY: Notable for left carotid endarterectomy and tracheostomy. She is status post an abdominal hysterectomy as well as a laminectomy.
ALLERGIES: None known.
CURRENT MEDICATIONS: Ampicillin sulbactam 1.5 g IVPB q. 6 h., carvedilol 12.5 mg p.o. b.i.d., cefazolin 2 g IVPB on-call for dental surgery, cetirizine 10 mg daily, cholecalciferol 2000 units daily, clotrimazole topical b.i.d., enoxaparin 40 mg subcu q. 24 hours, escitalopram 10 mg p.o. daily, famotidine 20 mg p.o. q. 12 h., furosemide 40 mg p.o. daily, gabapentin 100 mg p.o. at bedtime, lisinopril 5 mg b.i.d., menthol/zinc oxide topical b.i.d., and multivitamins one p.o. daily.
SOCIAL HISTORY: The patient is single. She never smoked cigarettes. She does not drink alcohol at this time.
FAMILY HISTORY: The patient’s mother had coronary artery disease and died in her 40s. Her father died of cancer. There is no known family history of diabetes or hypertension.
REVIEW OF SYSTEMS: See the history of present illness. A 14-point review of systems was performed. Review of systems is notable for nonproductive cough, dyspnea, and wheezing.
PHYSICAL EXAMINATION:
GENERAL APPEARANCE: No acute distress. The patient is obese. A tracheostomy is in place.
VITAL SIGNS: Temperature 36.6, blood pressure 154/72, pulse 64, respiratory rate 20, SpO2 98%, FiO2 10.0 liters.
HEENT: Pupils are round and reactive to light and accommodation. The oropharynx is clear.
NECK: A tracheostomy is in place. Carotid upstrokes are 2+. The jugular venous pressure is difficult to assess.
LUNGS: There are diffuse rhonchi and wheezes but no rales.
HEART: There is an irregularly irregular rhythm. The first and second heart sounds are of variable intensity. There is a grade 2/6 systolic murmur heard best at the left sternal border. There is no definite third heart sound.
ABDOMEN: Obese. Bowel sounds are present. There is no hepatosplenomegaly.
EXTREMITIES: There is no cyanosis, clubbing or edema.
SKIN: No rash or ecchymosis.
LABORATORY DATA: Glucose 96, sodium 140, potassium 4.0, chloride 100, CO2 of 32, BUN 16, creatinine 0.7, hemoglobin 10.6, platelets 290. PT 16.4, INR 1.5. Hematocrit 34.2.
DIAGNOSTIC DATA: Electrocardiogram performed revealed atrial fibrillation with a controlled ventricular response of 82 beats per minute. There is left axis deviation. A left bundle branch block is present. Cardiac echo performed. The left ventricular size was normal. There was moderate left ventricular systolic dysfunction with a left ventricular ejection fraction of 43%. There was a severe left ventricular diastolic abnormality and paradoxical septal motion consistent with a left bundle branch block. The left atrium was severely enlarged. There was moderate right ventricular hypertrophy and pulmonary hypertension. The right ventricular systolic pressure was 55 mmHg plus right atrial pressure.
IMPRESSION:
1. The patient’s cardiovascular risk for dental surgery is low to moderate. She does have mild systolic and significant diastolic heart failure. This can be managed medically without much difficulty. There is no history of recent myocardial infarction. Her most significant risk appears to be respiratory. She does have pulmonary hypertension and a history of respiratory failure.
2. Atrial fibrillation, rate controlled.
3. Hypertension, poorly controlled.
RECOMMENDATIONS: We concur with Dr. John Doe, present management with Lovenox as a bridge to surgery while her warfarin has been held. The patient’s lisinopril dose is quite low and will be increased as per orders. The carvedilol will be increased as well.
