DATE OF CONSULTATION: MM/DD/YYYY
REFERRING PHYSICIAN: John Doe, MD
CONSULTANT: Jane Doe, MD
REASON FOR CONSULTATION: Not dictated.
HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old female who presented to the emergency department with abdominal pain and peritonitis. The patient has been treated for that, but she does also have a history of peripheral vascular disease and is scheduled to undergo surgery within the next 3 weeks. The patient requires cardiac clearance and had been scheduled for outpatient stress test this week, which she was unable to make due to her hospitalization. At this time, the patient denies any anginal symptoms. Prior to her MI, she had complaints of left arm pain but no chest pain.
PAST MEDICAL HISTORY: Significant for peripheral vascular disease, history of coronary disease with previous myocardial infarction and angioplasty. She has a history of diabetes; hypertension; dyslipidemia; COPD; and end-stage renal disease, on peritoneal dialysis.
HOME MEDICATIONS: The patient is on Hectorol 2.5 mcg daily; Altace 2.5 mg daily; Plavix 75 mg daily; Renagel daily; Amaryl 2 mg daily; aspirin 1 daily; Toprol-XL 100 mg daily; Norvasc 10 mg daily; Catapres patch weekly; iron supplement; Lipitor 20 mg daily; potassium supplement 10 mEq daily; and Fosrenol 500 mg 3 times a day.
SOCIAL HISTORY: The patient does have a history of tobacco use. She does not use alcohol or illicit drugs.
REVIEW OF SYSTEMS:
GENERAL: No complaint of fever, chills or weight loss.
CARDIOVASCULAR: Denies any chest pain or anginal equivalent. No complaint of palpitations.
RESPIRATORY: Positive for shortness of breath secondary to COPD with no acute change in her status.
GASTROINTESTINAL: Positive for abdominal pain and peritonitis. No blood in bowel movements or dark tarry stools.
GENITOURINARY: End-stage renal disease, on dialysis.
NEUROLOGICAL: No TIA or CVA symptoms.
GENERAL: The patient is a (XX)-year-old female in no acute distress.
VITAL SIGNS: Stable. The patient is afebrile.
NECK: No jugular venous distention or carotid bruits.
HEART: Regular rate and rhythm. No murmurs are heard.
LUNGS: Clear bilaterally.
ABDOMEN: Moderately tender throughout due to peritonitis, was not deeply palpated. Bowel sounds present.
EXTREMITIES: No edema or cyanosis. She has faint peripheral pulses on the left; pulses on the right were nonpalpable.
NEUROLOGICAL: No focal deficits.
DIAGNOSTIC DATA: EKG is not done at this time.
LABORATORY STUDIES: CBC: WBC is 13.2, hemoglobin 10.4, hematocrit 31.6, and platelet count 184. Metabolic panel: Potassium is 4.8, BUN 49, creatinine 8.6, and TSH is within normal limits.
1. Coronary disease with history of myocardial infarction, status post percutaneous transluminal coronary angioplasty and stent.
2. Peripheral vascular disease.
3. End-stage renal disease, on peritoneal dialysis.
4. Peritonitis, stable.
5. Chronic obstructive pulmonary disease with history of tobacco use.
6. Diabetes mellitus.
RECOMMENDATIONS: The patient is scheduled for peripheral vascular surgery. We will proceed with a dual isotope stress test and 2D echocardiogram for clearance and obtain a 12-lead EKG for baseline.
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