DATE OF CONSULTATION: MM/DD/YYYY
REFERRING PHYSICIAN: John Doe, MD
REASON FOR CONSULTATION: Sinus bradycardia.
HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old female with a history of diabetes mellitus, hypertension, acute renal failure, peripheral vascular disease, and bilateral above-the-knee amputation. The patient presented from the nursing home with mental status change. On ED arrival, she had sinus bradycardia in the 30s, potassium was 6.4. She has been on Lopressor in the nursing home, and it was noted on the last admission, last month, that she was to be taken off Lopressor. Currently, she is in sinus rhythm with heart rate of 60s after atropine has been given.
PAST MEDICAL HISTORY: As stated in the history of present illness.
MEDICATIONS: Medications at the nursing home are Norvasc, Lipitor, hydralazine, Remeron, nitroglycerin patch, Lopressor, Pepcid, Procrit, and Nephro-Vite.
ALLERGIES: PENICILLIN.
SOCIAL HISTORY: The patient is from the nursing home. There is no tobacco, alcohol or illicit drug use noted.
FAMILY HISTORY: Noncontributory.
REVIEW OF SYSTEMS: A 10-point review of systems is negative other than what is stated in the history of present illness.
PHYSICAL EXAMINATION:
VITAL SIGNS: Temperature 97.6 degrees, pulse 66, respirations 16, and blood pressure 134/52.
GENERAL: This is an obese female who is in apparent distress. The patient is alert and oriented to person and place.
HEENT: PERRLA. Normocephalic.
NECK: No thyromegaly. No carotid bruits. No JVD.
HEART: Regular rate and rhythm. Normal S1, S2. No S3, S4. No murmurs, rubs or clicks.
LUNGS: Clear to auscultation bilaterally.
ABDOMEN: Soft, nontender. Positive bowel sounds at upper quadrant.
EXTREMITIES: No edema noted, bilateral lower extremities. Bilateral above-the-knee amputation noted.
DIAGNOSTIC DATA: EKG initially presented with junctional rhythm rate, 30, now sinus rhythm with a rate of 66.
LABORATORY DATA: Sodium 152, potassium 4.5, BUN 126, creatinine 5.6, and glucose 120. White count is 8.8, hemoglobin 11.8, hematocrit 34.8, and platelets 216,000. Troponins negative x2.
IMPRESSION:
1. Sinus bradycardia with a history of junctional rhythm, offered beta-blockers last admission.
2. Acute renal failure with hyperkalemia, now resolving.
3. Diabetes mellitus.
4. Hypertension.
5. Peripheral vascular disease with bilateral above-the-knee amputation.
6. Normal left ventricular function with ejection fraction of 60-65% with bilateral atrial enlargement on echocardiogram last admission.
PLAN: We will discontinue Lopressor once again. Atropine has been given. Ordered for thyroid panel, we will review. A 12-lead EKG has been ordered and reviewed. Continue to hold blood pressure medications at this time.
