Consult - History and Phy.
Sample Name: Cardiomyopathy & Hypotension - Consult
Description: Cardiomyopathy and hypotension. A lady with dementia, coronary artery disease, prior bypass, reduced LV function, and recurrent admissions for diarrhea and hypotension several times.
(Medical Transcription Sample Report)
REASON FOR CONSULTATION: Cardiomyopathy and hypotension.
HISTORY OF PRESENT ILLNESS: I am seeing the patient upon the request of Dr. X. The patient is very well known to me, an 81-year-old lady with dementia, a native American with coronary artery disease with prior bypass, reduced LV function, recurrent admissions for diarrhea and hypotension several times in November and was admitted yesterday because of having diarrhea with hypotension and acute renal insufficiency secondary to that. Because of her pre-existing coronary artery disease and cardiomyopathy with EF of about 30%, we were consulted to evaluate the patient. The patient denies any chest pain or chest pressure. Denies any palpitations. No bleeding difficulty. No dizzy spells.
REVIEW OF SYSTEMS:
CONSTITUTIONAL: No fever or chills.
EYES: No visual disturbances.
ENT: No difficulty swallowing.
CARDIOVASCULAR: Basically, no angina or chest pressure. No palpitations.
RESPIRATORY: No wheezes.
GU: No specific symptoms.
MUSCULOSKELETAL: Have sores on the back.
NEUROLOGIC: Have dementia.
All other systems are otherwise unremarkable as far as the patient can give me information.
PAST MEDICAL HISTORY:
1. Positive for coronary artery disease for about two to three years.
5. Congestive heart failure with EF of 25% to 30%.
7. Compression fractures.
8. Diabetes mellitus.
PAST SURGICAL HISTORY:
1. Coronary artery bypass grafting x3 in 2008.
4. ICD implantation.
CURRENT MEDICATIONS AT HOME:
2. Clavulanic acid or Augmentin every 12 hours.
3. Clopidogrel 75 mg daily.
4. Simvastatin 20 mg daily.
5. Sodium bicarbonate 650 mg twice daily.
6. Gabapentin 300 mg.
7. Levothyroxine once daily.
8. Digoxin 125 mcg daily.
9. Fenofibrate 145 mg daily.
10. Aspirin 81 mg daily.
11. Raloxifene once daily.
12. Calcium carbonate and alendronate.
13. Metoprolol 25 mg daily.
14. Brimonidine ophthalmic once daily.
ALLERGIES: She has no known allergies.
FAMILY HISTORY: Noncontributory to this admission.
SOCIAL HISTORY: She lives with husband, who is elderly, cannot take care of her. She does not smoke or drink alcohol currently.
GENERAL: Elderly in no apparent distress.
VITAL SIGNS: Heart rate of 71, blood pressure 116/48. Upon presentation, her blood pressure was in the 80s.
HEENT: Normocephalic and atraumatic. No thyromegaly or lymphadenopathy.
CARDIOVASCULAR: Carotid upstroke normal. Jugular venous pressure is about 7 cm of H2O. The heart is irregularly irregular with a normal S1 and S2. There is a 2/6 holosystolic murmur.
LUNGS: Clear to auscultation. No rales.
MUSCULOSKELETAL: No edema.
LABORATORY TESTS: Hemoglobin of 8.7, hematocrit 25.7. BUN 111; creatinine of 5.0, prior creatinine of 1.88 on 11/30/2009. Troponin of 0.09 with very elevated myoglobin of 575. The blood dipstick in the urine was moderate.
ASSESSMENT AND PLAN:
1. Elderly with rhabdomyolysis, acute renal insufficiency, secondary to diarrhea. Evaluate for C diff.
2. Hydration. Increase fluids to about 200 an hour. Consult with Nephrology.
3. Hold off beta-blockers at this time until blood pressure is more stable. May restart metoprolol 25 mg b.i.d.
4. No need for EF. Assessment plus EF is about 30% with mitral regurgitation on a very recent echocardiogram.
5. Further recommendations will depend on the blood pressure over the next 24 hours.
Keywords: consult - history and phy., palpitations, dizzy spells, reduced lv function, bypass, hypotension, beta-blockers, cardiomyopathy and hypotension, chest pressure, artery disease, renal insufficiency, coronary artery, blood pressure, creatinine, renal, insufficiency, chest, heart, coronary, artery, diarrhea, ef, cardiomyopathy, blood, pressure,