DATE OF CONSULTATION: MM/DD/YYYY
REFERRING PHYSICIAN: John Doe, MD
REASON FOR CONSULTATION: Surgical evaluation for emergency coronary artery bypass grafting (CABG).
HISTORY OF PRESENT ILLNESS: This is a (XX)-year-old man with no significant prior medical history. He was working, doing some lifting, and developed some heaviness in his chest, which was associated with diaphoresis and mild shortness of breath. Radiation to the left shoulder was also noted. There was no nausea or vomiting. He presented to the hospital and was admitted to the emergency department with acute coronary syndrome, unstable angina, and transferred for emergency cardiac catheterization, which revealed severe three-vessel coronary artery disease and severely impaired left ventricular function. An intra-aortic balloon pump was placed and we were consulted for surgical evaluation.
PAST MEDICAL AND SURGICAL HISTORY: Negative.
ALLERGIES: No known drug allergies.
MEDICATIONS: Prior to admission, none. In the emergency department, the patient received aspirin, nitroglycerin, heparin, some IV morphine, and Lopressor.
FAMILY HISTORY: Positive for mother dying of myocardial infarction in her 70s.
SOCIAL HISTORY: Negative for current tobacco or excessive alcohol intake. Apparently, the patient used to smoke, quit in his 60s.
REVIEW OF SYSTEMS: Except as noted above, the 10-point review of systems is negative.
PHYSICAL EXAMINATION:
GENERAL: This is a well-developed, well-nourished elderly Hispanic man, in no acute distress. Alert and oriented x3.
VITAL SIGNS: Blood pressure is 112/82, pulse is 82 and regular, and respirations are 60 and unlabored.
HEENT: Within normal limits. Sclerae are nonicteric. Oral mucosa moist.
NECK: Without bruits or jugular venous distension.
CHEST: Without significant abnormalities.
LUNGS: Clear to auscultation bilaterally with normal respiratory effort.
HEART: Regular rate and rhythm. Normal S1 and S2 without murmurs, rubs or gallops.
ABDOMEN: Soft and nontender without hepatosplenomegaly.
EXTREMITIES: Full range of motion to the extent that the exam could be performed. The patient has intra-aortic balloon pump in the right groin. There was no cyanosis, clubbing or edema. Distal pulses were 2+ and symmetric throughout.
NEUROLOGIC: Grossly intact and nonfocal.
LYMPHATICS: Without cervical or axillary adenopathy.
SKIN: Without obvious rash or lesion.
Cardiac catheterization films were reviewed with agreement with the above-mentioned findings.
IMPRESSION:
1. Severe three-vessel coronary artery disease.
2. Severely impaired left ventricular function.
3. Unstable angina.
PLAN: We will take the patient to the operating room for emergency coronary artery bypass grafting. Risks and benefits of the surgery were discussed with the patient and family with the risks including death, stroke, heart attack, infection, and bleeding. They expressed understanding of the risks and consented to proceeding.
