Sample Type / Medical Specialty: Consult - History and Phy.
Sample Name: Elevated Cardiac Enzymes
Description: Abnormal cardiac enzyme profile. The patient is a 66-year-old gentleman, was brought into emergency room with obtundation. The patient was mechanically ventilated originally. His initial diagnosis was septic shock. His labs showed elevated cardiac enzyme profile.
(Medical Transcription Sample Report)
REASON FOR CONSULTATION: Abnormal cardiac enzyme profile.
HISTORY OF PRESENT ILLNESS: The patient is a 66-year-old gentleman, was brought into emergency room with obtundation. The patient was mechanically ventilated originally. His initial diagnosis was septic shock. His labs showed elevated cardiac enzyme profile. This is a consultation for evaluation of the same. The patient is unable to give history. History obtained through the family members. As per the patient's son, he does not have history of cardiac disease. He lives in Utah, presently spending few months in Arizona. As I understand, he has been followed by a physician back in Utah and believes that he had some workup done from cardiac standpoint which has been negative so far. No prior history of chest pain, shortness of breath as per the family members.
CORONARY RISK FACTORS: History of hypertension, no history of diabetes mellitus, ex-smoker, cholesterol status borderline elevated, no prior history of coronary artery disease, and family history noncontributory.
FAMILY HISTORY: Nonsignificant.
SURGICAL HISTORY: Foot surgery as per the family members.
1. Vitamin supplementation.
4. Losartan 50 mg daily.
5. Nifedipine 90 mg daily.
7. Potassium supplementation.
PERSONAL HISTORY: He is an ex-smoker. Does not consume alcohol.
PAST MEDICAL HISTORY: Pulmonary fibrosis, on prednisone, oxygen-dependent cellulitis status post foot surgery with infection recuperating from the same. Presentation today with respiratory acidosis, septicemia and septic shock, presently on mechanical ventilation. No prior cardiac history. Elevated cardiac enzyme profile.
REVIEW OF SYSTEMS: Limited.
VITAL SIGNS: Pulse of 94, blood pressure 98/57, respiratory rate as per setting.
HEENT: Atraumatic and normocephalic.
NECK: Supple. Neck veins flat.
LUNGS: Air entry bilaterally clear, rales are scattered.
HEART: PMI displaced. S1, S2 regular. Systolic murmur, grade 2/6.
ABDOMEN: Soft, nontender.
EXTREMITIES: Chronic skin changes, markings in the lower extremities noted. Pulses found palpable. Dressing also noted.
LABORATORY AND DIAGNOSTIC DATA: EKG, normal sinus rhythm with wide complex. Labs, white count of 20,000, H&H 10 and 33, platelets of 163, INR 1.36, BUN of 158, creatinine 8.7, potassium 7.3, of bicarbonate is 11. Cardiac enzyme profile, troponin 0.05, total CK 312, myoglobin 1423. Chest x-ray, no acute changes.
1. The patient is a 66-year-old gentleman with pulmonary fibrosis, on prednisone, oxygen dependent with respiratory acidosis.
2. Septicemia, septic shock secondary to cellulitis of the leg.
3. Acute renal shutdown.
4. Elevated cardiac enzyme profile without prior cardiac history possibly due to sepsis and also acute renal failure.
1. Echocardiogram to assess LV function to rule out any cardiac valvular involvement.
2. Aggressive medical management including dialysis.
3. From cardiac standpoint, conservative treatment at this juncture. His cardiac enzyme profile could be elevated secondary to sepsis and also underlying renal failure.
4. Explained to patient's family in detail regarding condition which is critical which they are aware of.
Keywords: consult - history and phy., pulmonary fibrosis, prednisone, oxygen dependent, respiratory acidosis, septicemia, septic shock, cellulitis, elevated cardiac enzyme profile, cardiac enzyme profile, cardiac history, renal failure, cardiac enzymes, cardiac, enzymes,