DATE OF CONSULTATION: MM/DD/YYYY
REFERRING PHYSICIAN: John Doe, MD
REASON FOR CONSULTATION: Lightheadedness.
HISTORY OF PRESENT ILLNESS: This is a very pleasant (XX)-year-old male with a previous history of CVA, chronic essential hypertension, COPD, and diabetes mellitus. He presents to hospital after two episodes of dizziness. Apparently, on Monday, the patient had his first event. He claims he was walking across the room and suddenly he became very dizzy. The patient does not have a clear recollection of exactly what had happened. He, however, does deny any loss of consciousness. He states his feet may have been fumbling and may have been off balance a bit, but he cannot be sure. The next event occurred yesterday with similar presentation. Given the patient’s history of CVA, family was concerned and recommended the patient go to ER for evaluation. The patient denies any associated chest pain and palpitations with these events. He admits to not feeling well this weekend with diarrhea and decreased p.o. intake. He denies any shortness of breath.
He denies any nausea, vomiting, melena, hematochezia, hematuria or dysuria. He has no history of documented coronary artery disease. He was previously seen by us in the past, status post his first CVA. At that time, he had an echocardiogram done, which revealed no gross structural disease. He states he has not had any myocardial infarctions or cardiac issues in the interim.
PAST MEDICAL HISTORY: As noted.
MEDICATIONS AT HOME: Include simvastatin 20 mg daily, terazosin 10 mg daily, metformin 1000 mg twice a day, potassium 80 mEq three times a day, aspirin 81 mg daily, Lasix 20 mg three times a day, metoprolol 100 mg half twice daily, glipizide 10 mg b.i.d., and diltiazem 120 mg daily.
ALLERGIES: The patient denies any drug allergies.
REVIEW OF SYSTEMS: Pertinent review of systems is as noted above. Otherwise, 14 point review of systems is negative and noncontributory.
SOCIAL HISTORY: The patient denies any past history of tobacco abuse. No history of excessive alcohol use/excessive drug use.
FAMILY HISTORY: Significant for CVAs; however, no premature atherosclerotic heart disease.
PHYSICAL EXAMINATION:
GENERAL: This is a pleasant (XX)-year-old male who answers questions appropriately.
VITAL SIGNS: Blood pressure at admission 168/94, pulse is 78, respirations are 18, satting 95% on room air, and temperature 98.2 degrees.
HEENT: Head is normocephalic and atraumatic. Extraocular muscles are intact. Pupils are equal, round, and reactive to light.
NECK: There is no jugular venous distention with the patient about 35 degrees.
LUNGS: Breath sounds are grossly clear bilaterally.
HEART: Irregular. There is normal S1 and S2. There are no appreciable murmurs. No visible palpable precordial thrills or heaves.
ABDOMEN: Soft, nontender, and nondistended x4 quadrants. Audible bowel sounds.
EXTREMITIES: Warm with 1+ pretibial and pedal edema.
PERIPHERAL VASCULAR: Carotids are palpable. Peripheral pulses are difficult to palpate given extremity edema.
LABORATORY DATA: WBC is 6.2, H&H 13.4 and 41.4, and platelet count is 104,000. Sodium is 144, potassium is 3.4 with a repeat of 3.6, BUN is 8 and creatinine is 1. Liver panel is within normal limits. CK-MB is 2.4 and troponin is 0.03.
DIAGNOSTIC DATA: Chest x-ray shows cardiomegaly with small right pleural effusion. CT of the brain shows diffuse atrophy, extensive white matter changes suggestive of small vessel disease, encephalomalacia in the right occipital lobe, probable old deep white matter infarct in the subcortical frontal lobe.
EKG shows sinus rhythm with PVCs and PACs. There is normal axis. QRS is 114, nonspecific intraventricular conduction delay. There are no acute ST or T-wave changes. No Q waves.
IMPRESSION:
1. Lightheadedness. Suspect probably component of some hypovolemia given recent diarrhea. The patient has a history of cerebrovascular accident; although, CT shows no new/acute findings to suggest cerebrovascular accident. Echo was reviewed and shows normal ejection fraction. EKG shows no ischemic changes and cardiac enzymes are negative x1.
2. Hypertension, uncontrolled.
3. Chronic obstructive pulmonary disease.
4. Cerebrovascular accident in the past.
5. Diabetes mellitus.
6. Pulmonary hypertension with PA pressure on echocardiogram about 65 to 70.
7. Lower extremity edema. No clinically gross congestive heart failure. Question whether lower extremity component of vasculopathy secondary to diabetes.
RECOMMENDATIONS:
1. We will follow for cardiac enzymes.
2. We will check orthostatics.
3. IV fluids.
4. We will adjust medications for blood pressure goal less than 130/80. We have discussed with the patient further cardiac workup. He does not want invasive workup. We will await MRI/neurology evaluation as well.
