DATE OF CONSULTATION: MM/DD/YYYY
REFERRING PHYSICIAN: John Doe, MD
REASON FOR CONSULTATION: Pacemaker interrogation.
HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old patient who has a history of ischemic cardiomyopathy, EF 30-35%; status post Medtronic AICD; history of ventricular arrhythmias; history of inferior wall myocardial infarction; coronary artery bypass graft with subsequent PCI, right coronary artery; hypertension; dyslipidemia; chronic atrial fibrillation, on Coumadin therapy; dementia; hard of hearing; obstructive sleep apnea, uses CPAP; and renal insufficiency. History was obtained from the chart and his wife due to his history of dementia.
The patient’s wife said he has been coughing for about three days, now is a dry cough, acting very bizarre, mental status change, shortness of breath, elevated blood pressure, so she brought him to the emergency department for evaluation. We were called for pacemaker interrogation for possible pacemaker malfunction. The patient denies any chest pain, shortness of breath, shocks, syncope or palpitations.
PAST MEDICAL HISTORY: As above.
PAST SURGICAL HISTORY: CABG and subsequent stent to the right coronary artery, status post AICD, status post laminectomy.
SOCIAL HISTORY: Married. The patient denies tobacco, alcohol or drugs.
FAMILY HISTORY: Noncontributory.
RISK FACTORS: Age, hypertension, and dyslipidemia.
ALLERGIES: None.
MEDICATIONS: Zetia 10 mg daily; Diovan 80 mg daily; aspirin 81 mg daily; Pravachol 40 mg daily; Coumadin 2 mg daily; Coreg 12.5 mg b.i.d.; Maxzide 37.5 mg daily; Zemplar; and amiodarone 200 mg daily.
PHYSICAL EXAMINATION:
GENERAL: Alert, confused (XX)-year-old Hispanic male in no acute distress.
VITAL SIGNS: Blood pressure 136/76, heart rate 66, respirations 18, temperature 97.8 degrees.
HEENT: Within normal limits.
NECK: No carotid bruits, JVP or thyromegaly.
HEART: AICD noted. Left subclavian incisions are benign.
LUNGS: Wheezing, bilateral. Positive cough with deep expiration.
ABDOMEN: Soft, nontender.
EXTREMITIES: No edema.
LABORATORY DATA: BNP is 454. Troponins negative x1. INR 1.88. WBC 6.2, hemoglobin 11.4, hematocrit 34.4, and platelet 196,000. LFTs completely normal. Sodium 141, potassium 4.5, chloride 108, CO2 of 26, BUN 28 and creatinine 1.8, and glucose 178.
DIAGNOSTIC DATA: Chest x-ray: Cardiomegaly. Lungs are clear. EKG: Atrial fibrillation, 70 beats per minute with nonspecific ST changes. V/Q lung: Intermediate probability for pulmonary embolus. CT without contrast showed infiltrate, left lower lobe, status post sternotomy.
IMPRESSION:
1. Pacemaker malfunction. We will have Medtronic interrogate for us.
2. Admitted with pneumonia. V/Q lung scan, intermediate probability for pulmonary embolus, on chronic Coumadin therapy. INR is 1.88.
3. Ischemic cardiomyopathy, status post automatic implantable cardioverter-defibrillator. BNP is elevated at 454.
4. History of myocardial infarction, coronary artery disease, coronary artery bypass graft, stent to the right coronary artery. Troponins negative x1.
5. History of ventricular arrhythmias, on amiodarone.
6. Hypertension, blood pressure stable.
7. Dyslipidemia, on Zetia and Pravachol.
8. Chronic atrial fibrillation, on chronic Coumadin therapy. INR is subtherapeutic.
9. Dementia.
10. Obstructive sleep apnea, uses continuous positive airway pressure.
11. Renal insufficiency.
PLAN AND RECOMMENDATIONS: Monitor on telemetry, check AICD interrogate, resume her medications, and review records. Further recommendations to follow throughout the clinical course.
Thank you, Dr. Doe, for consulting us. We will be following along closely with you.
