DATE OF CONSULTATION: MM/DD/YYYY
REFERRING PHYSICIAN: John Doe, MD
REASON FOR CONSULTATION: Questionable wide-complex tachycardia and change in level of consciousness.
HISTORY OF PRESENT ILLNESS: This (XX)-year-old male was seen in consult after presenting to the emergency department after being found unresponsive this a.m. by his significant other. She states that she awakened to him pulling at the bed covers but was not verbally responsive, and he was not able to follow verbal commands. She subsequently called the paramedics, and he was transported to the emergency department. Upon arrival to the ED, he was very agitated and had to be restrained. Now, his left side is not moving. He does arouse to verbal stimuli but still continues to not follow verbal commands. He was placed on lidocaine drip for a wide-complex tachycardia. He was also given Lasix 80 mg IV for chest x-ray showing pulmonary edema. He does have nonischemic heart disease and is status post aortocoronary bypass in the distant past. He also has a permanent pacemaker. Apparently, he has continued with regular pacemaker checks. He is on chronic Coumadin anticoagulation for atrial fibrillation, which is followed by his primary care physician. According to his significant other, his last INR was checked approximately two weeks ago. He also does have a history of ventricular ectopy.
CARDIAC RISK FACTORS: Hypertension, known ischemic heart disease, questionable lipid status.
PAST MEDICAL HISTORY: No chronic lung, hepatic or endocrine disorders. He does have a history of renal artery stenosis and a prior history of CVA.
PAST SURGICAL HISTORY: Aortocoronary bypass in the distant past with saphenous vein graft to two marginal branches, the right coronary artery, and LIMA to the LAD. He also has a history of permanent pacemaker insertion and repair of ankle fracture.
ALLERGIES AND REACTIONS: None known.
CURRENT MEDICATIONS: Coumadin 5 mg every other day, atenolol 25 mg daily, and Antivert 12.5 mg p.r.n. dizziness.
PHYSICAL EXAMINATION:
VITAL SIGNS: Blood pressure 168/78.
GENERAL: This is an elderly male. He arouses to verbal stimuli but does not follow verbal commands.
NECK: No JVD or carotid bruits noted.
LUNGS: Have decreased breath sounds at both bases.
HEART: Heart rhythm is irregularly irregular. There is a systolic outflow murmur noted.
ABDOMEN: Obese. Liver and spleen are nonpalpable.
EXTREMITIES: Intact with no pedal edema. There is no movement noted at left upper and lower extremities.
LABORATORY DATA: A 12-lead electrocardiogram shows atrial fibrillation, heart rate of 78 with LVH and diffuse T-wave abnormalities. Sodium 138, potassium 4.2, chloride 108, CO2 of 21, BUN of 18, creatinine 1.0, troponin 0.09, and INR 1.6.
DIAGNOSTIC DATA: CT scan of the brain shows no acute process. Chest x-ray compatible with CHF.
IMPRESSION:
1. Change in level of consciousness, questionable cerebrovascular accident.
2. Atrial fibrillation, chronic.
3. Status post permanent pacemaker insertion.
4. Ischemic heart disease, rule out myocardial infarction.
5. Chronic heart failure.
6. Subtherapeutic INR.
7. Hypertension.
8. Questionable wide complex tachycardia versus atrial fibrillation with aberrancy.
9. Mitral regurgitation.
PLAN:
1. We will admit to ICU.
2. We will obtain echocardiogram, carotid duplex studies, and cardiac enzymes.
3. We would recommend neurological consult.
4. Pacemaker interrogation.
5. IV beta blockers.
6. We will hold Coumadin until cleared by Neurology.
7. Further recommendations to be based upon clinical course.
