Consult - History and Phy.
Sample Name: Ventricular Ectopy - Consult
Description: Ventricular ectopy and coronary artery disease. He is a 69-year-old gentleman with established history coronary artery disease and peripheral vascular disease with prior stent-supported angioplasty.
(Medical Transcription Sample Report)
REASON FOR CONSULTATION: Ventricular ectopy and coronary artery disease.
HISTORY OF PRESENT ILLNESS: I am seeing the patient upon the request of Dr. Y. The patient is a very well known to me. He is a 69-year-old gentleman with established history coronary artery disease and peripheral vascular disease with prior stent-supported angioplasty. The patient had presented to the hospital after having coughing episodes for about two weeks on and off, and seemed to have also given him some shortness of breath. The patient was admitted and being treated for pneumonia, according to him. The patient denies any chest pain, chest pressure, or heaviness. Denies any palpitations, fluttering, or awareness of heart activity. However, on monitor, he was noticed to have PVCs random. He had run off three beats consecutive one time at 12:46 p.m. today. The patient denied any awareness of that or syncope.
REVIEW OF SYSTEMS:
CONSTITUTIONAL: No fever or chills.
EYES: No visual disturbances.
ENT: No difficulty swallowing.
CARDIOVASCULAR: Prior history of chest discomfort in 08/2009 with negative stress study.
RESPIRATORY: Cough and shortness of breath.
NEUROLOGIC: Otherwise unremarkable.
ENDOCRINE: Otherwise unremarkable.
HEMATOLOGIC: Otherwise unremarkable.
ALLERGIC: Otherwise unremarkable.
PAST MEDICAL HISTORY:
1. Positive for coronary artery disease since 2002.
2. History of peripheral vascular disease for over 10 years.
PAST SURGICAL HISTORY: Right fem-popliteal bypass about eight years ago, neck fusion in the remote past, stent-supported angioplasty to unknown vessel in the heart.
MEDICATIONS AT HOME:
1. Aspirin 81 mg daily.
2. Clopidogrel 75 mg daily.
3. Allopurinol 100 mg daily.
4. Levothyroxine 100 mcg a day.
6. Metoprolol 25 mg a day.
7. Atorvastatin 10 mg daily.
ALLERGIES: THE PATIENT DOES HAVE ALLERGY TO MEDICATION. HE SAID HE CANNOT TAKE ASPIRIN BECAUSE OF INTOLERANCE FOR HIS STOMACH AND STOMACH UPSET, BUT NO TRUE ALLERGY TO ASPIRIN.
FAMILY HISTORY: No history of premature coronary artery disease. One daughter has early onset diabetes and one child has asthma.
SOCIAL HISTORY: He is married and retired. He has nine children, 25 grandchildren. He smokes one pack per day. He smoked 50 pack years and had no intention of quitting according to him.
VITAL SIGNS: Temperature of 97, heart rate of 90, blood pressure of 187/105.
HEENT: Normocephalic and atraumatic. No thyromegaly or lymphadenopathy.
CARDIOVASCULAR: Upstroke is normal. Distal pulse symmetrical. Heart regular with a normal S1 with normally split S2. There is an S4 at the apex.
LUNGS: With decreased air entry. No wheezes.
ABDOMINAL: Benign. No masses.
EXTREMITIES: No edema, cyanosis, or clubbing.
NEUROLOGIC: Awake, alert, and oriented x3. No focal deficits.
IMAGING STUDIES: Echocardiogram on 08/26/2009, showed mild biatrial enlargement, normal thickening of the left ventricle with mildly dilated ventricle, EF of 40%, mild mitral regurgitation, and diastolic dysfunction, grade 2.
Nuclear stress study in 08/2009 showed fixed inferolateral defects, no reversible ischemia identified.
Chest x-ray upon this presentation showed no acute disease.
LABORATORY DATA: Showed normal white cells, hemoglobin 11. BUN of 12.1, creatinine of 0.8. Troponin of 0.04. BNP of 5700.
ASSESSMENT AND PLAN:
1. Elderly with cardiomyopathy, ischemic. The patient presenting with exacerbation of symptoms. He was not taking beta-blockers accurately. He was on a lower dose of lisinopril, hypertension not optimal. The patient at this time, maximum medical treatment will be recommended. Recent testing showed no reversible ischemia.
2. Consideration for EP consultation later for evaluation for ventricular tachycardia or necessity for defibrillator will be determined at a later time after the patient is treated for his COPD exacerbation and pneumonia.
3. Continue metoprolol, would be better to have a little higher dose, we will increase it to 25 mg b.i.d. Continue atorvastatin.
4. Increase lisinopril to 20 mg daily to improve blood pressure management.
5. Adding hydralazine also will be of help for blood pressure management.
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