DATE OF CONSULTATION: MM/DD/YYYY
REFERRING PHYSICIAN: John Doe, MD
REASON FOR CONSULTATION: Preoperative evaluation and pleural effusions.
HISTORY OF PRESENT ILLNESS: This is a very pleasant (XX)-year-old who is being prepared for VSD repair. As a part of preoperative clearance, we were asked to assist in her evaluation. Apparently, she came in with congestive heart failure and has bilateral pleural effusions. She is currently being diuresed. Her last x-ray was done 10 days ago; there was no x-ray after that. There was a MRI done, and this MRI did show bilateral effusions. When we came to see the patient, she was on room air, in no acute distress, and no chest pain or shortness of breath.
PAST MEDICAL HISTORY: Congestive heart failure, history of MI with subsequent VSD, recent cath showed an EF of about 50%, hypertension, hyperlipidemia, CDT colitis on this admission, and diverticulitis.
ALLERGIES: MULTIPLE MEDICATION ALLERGIES.
SOCIAL HISTORY: The patient lives with her son. She does not smoke or drink.
FAMILY HISTORY: Noncontributory.
REVIEW OF SYSTEMS:
CONSTITUTIONAL: No fevers, night sweats, or weight loss.
CENTRAL NERVOUS SYSTEM: No history of seizures, strokes, or migraine headaches.
CARDIAC: See history of present illness.
PULMONARY: Never had asthma or emphysema.
GASTROINTESTINAL: No ulcers, colitis, or hepatitis.
GENITOURINARY: No kidney or bladder problems.
MUSCULOSKELETAL: No history of gout or rheumatoid arthritis.
All other systems are negative.
PHYSICAL EXAMINATION:
GENERAL: The patient is awake and responsive, in no acute distress.
VITAL SIGNS: Blood pressure 92/52, pulse is 86, respirations 18.
HEENT: Pupils are round and reactive. Sclerae anicteric.
NECK: Supple without JVD, goiter or carotid artery bruit.
HEART: S1 and S2. There is a 2/6 systolic murmur. No gallops.
LUNGS: Good breath sounds but diminished at the bases. No dullness to percussion. No rhonchi or wheezes.
ABDOMEN: Soft and nontender. No organomegaly.
EXTREMITIES: No edema. No clubbing. Pulses are palpable and equal bilaterally.
SKIN: Warm. No rash.
LYMPH NODES: Not palpated in the neck, supraclavicular, or axillary area.
NEUROLOGIC: Cranial nerves are intact. No motor or sensory deficit.
LABORATORY DATA: From yesterday showed a white count of 6500, H&H 11.2 and 33.6, and platelet count 168,000. Sodium 130, potassium 3.9, chloride 102, bicarbonate 26, BUN 8, and creatinine 0.7.
DIAGNOSTIC DATA: Last x-ray was done 10 days ago, and this showed cardiomegaly with bilateral pleural effusions and basilar atelectasis. A repeat x-ray is pending. A cardiac catheterization that was done a month ago showed mild pulmonary hypertension with VSD. Pulmonary artery pressure was 40/10.
IMPRESSION: This is a very pleasant Hispanic female with a recent admission for congestive heart failure exacerbation, possibly small heart attack, who now has a ventricular septal defect that needs to be repaired. From the pulmonary standpoint, the patient was in congestive heart failure but seems to be better compensated at this time. The last x-ray was done 10 days ago. The patient does have little diminished breath sounds at the bases suggestive of possibly some residual effusions.
RECOMMENDATIONS:
1. Repeat chest x-ray, PA and lateral.
2. From the pulmonary standpoint, we do not see anything that would prevent her from going to surgery.
Thank you, Dr. Doe, for consulting us. We will follow the patient along with you.
