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Coronary Revascularization Consult Transcription Sample

REASON FOR CONSULTATION:  We were asked to give our opinion about possible coronary revascularization.

HISTORY OF PRESENT ILLNESS:  The patient is a very pleasant (XX)-year-old African-American gentleman.  He presented with worsening congestive heart failure, which he is known to have recent onset of.  He was transferred after a second admission for pulmonary edema and congestive heart failure.  The patient was recently admitted with an EF of 40-45% and inferior wall motion abnormality.  The plans were for elective heart cath; however, this was moved up.  The patient was treated with intravenous Lasix prior with some improvement in his shortness of breath.  He states that he has had also shortness of breath after walking a few blocks.  He has had no lower extremity edema and has had no prior myocardial infarction to his knowledge.  The patient was ruled out for myocardial infarction but had an elevated BNP of over 1000.  The patient underwent cardiac catheterization today, which revealed an ejection fraction of 30-35% and severe triple-vessel coronary artery disease with 50-60% left main coronary stenosis.  The patient denies any syncopal episodes, palpitations, or presyncopal episodes.  He denies any nausea or vomiting, but he does have a chronic cough.

PAST MEDICAL HISTORY:  The patient has significant past medical history, including hypertension, heavy tobacco abuse, and heavy alcohol abuse.  He also has remote history of IV drug abuse.

PAST SURGICAL HISTORY:  None.

MEDICATIONS:  Lasix, Isordil, lisinopril, potassium, aspirin, Coreg, gabapentin, bupropion, Geodon, Haldol, Prozac, Trileptal, and lorazepam.

ALLERGIES:  No known drug allergies.

SOCIAL HISTORY:  The patient lives alone.  He is a heavy tobacco abuser, 1-1/2 packs a day for (XX) years.  He was a heavy alcohol abuser but states that he quit.  He had a prior IV drug abuse history.

FAMILY HISTORY:  Significant for no premature coronary artery disease, congestive heart failure.  His sister died of colon cancer.  He had the usual childhood illnesses but denies rheumatic fever.

REVIEW OF SYSTEMS:
NEUROLOGICAL:  The patient denies any strokes, TIA, headaches or seizures.  The patient does have schizophrenia and is on Haldol for this.
PULMONARY:  The patient denies COPD or asthma but does have a chronic congestive-type cough, which is productive.  He has no hemoptysis noted.  He is a heavy tobacco abuser as noted.  No recent PFTs noted.
GENITOURINARY:  The patient denies any nocturia, frequency, urinary tract infections or kidney stone disease.
CARDIOVASCULAR:  The patient denies any myocardial infarctions but does have what we believe is New York Heart class II, class III congestive heart failure with exacerbations.  No atrial fibrillation.
GASTROINTESTINAL:  The patient denies any GI malignancies, constipation, or diarrhea.
MUSCULOSKELETAL:  The patient denies any arthritic complaints, myalgias, or neuralgias.
HEMATOLOGIC:  The patient denies any bleeding or unusual hemorrhage or thrombus.  He states that he had an HIV test many years ago.  Quit using IV drugs many years ago.  This was negative by report only, however.
ENDOCRINE:  The patient denies any thyroid problems but does have hyperlipidemia.  He does have hypertension.  Does not have diabetes mellitus.

PHYSICAL EXAMINATION:
GENERAL:  On exam, the patient is a seemingly poorly nourished, well-developed, (XX)-year-old gentleman.  Skin turgor is normal.  He is not diaphoretic.  He is alert and oriented x3.
VITAL SIGNS:  Blood pressure 162/100.  Heart rate 80 beats per minute.  Oxygen saturation 90% on room air.  Temperature 36.8 degrees Centigrade.  Respiratory rate 20 and comfortable.  He is lying flat on his bed.
HEENT:  Normocephalic and atraumatic head.  Extraocular muscles are intact.  He has no scleral icterus.  He has normal hair distribution.
NECK:  Trachea is midline.  He has no carotid bruits.  He has 2+ carotid pulsations.  He has no significant JVD appreciated.  He has no supraclavicular or infraclavicular lymphadenopathy.  His tongue is midline with no oral thrush noted.
LUNGS:  The patient has loud expiratory wheezes bilaterally, chronic cough with rhonchi throughout.
CHEST:  He has no chest wall bony abnormalities.  He does have good thoracic excursion, however.
HEART:  The patient has regular rate and rhythm.  No murmurs, clicks, or rubs noted.
ABDOMEN:  The patient has no organomegaly.  No ascites.  He has nontender exam with normoactive bowel sounds.  There is no rebound.  He has no herniations or scars on his abdomen.
EXTREMITIES:  The patient has 2+ radial pulses.  He has no clubbing or cyanosis appreciated.  He has full range of motion x4.  He has 1 to 2+ DP, PT pulses primarily.  There are no ulcerations on his lower extremities.  There is no brawny edema.
NEUROLOGIC:  He has no gross motor or sensory deficits appreciated.

LABORATORY DATA:  Revealed HDL cholesterol of 26, LDL was 136, total cholesterol was 201.  White blood cell count 5.4.  Hemoglobin 14.4 g/dL.  Platelet count 246,000.  BUN is 22 and creatinine is 1.1.  Sodium 134, potassium 4.2.  Albumin is 4.2.  Liver profile is within normal limits.  INR is 1.1.  Urinalysis was negative for UTI.  BNP was over 1000.

IMPRESSION:
1.  Severe triple-vessel coronary artery disease.
2.  Moderate left main stenosis.
3.  Congestive heart failure, New York Heart class III.
4.  Chronic cough with pulmonary congestion.
5.  Heavy tobacco abuse history.
6.  Schizophrenia.
7.  Hypertension.
8.  Heavy alcohol abuse, history with intravenous drugs as well.
9.  Dilated cardiomyopathy with ejection fraction of 35%.

RECOMMENDATIONS:
1.  Pulmonary consultation to optimize the patient's pulmonary function prior to surgical intervention.
2.  Medical optimization by the cardiology service to optimize cardiac function from his congestive heart failure and coronary status.
3.  Chest x-ray.
4.  PFTs and ABG.
5.  Repeat echo in one week.

We have clearly described the above procedure, its benefits, risks, and alternatives to the patient.  We feel that the patient is a prohibitive operative risk at this time secondary to his multiple comorbidities.  Over the next few weeks, we will be able to get the patient optimized for coronary vascularization.  Operative mortality at this point is at least 20% with risk of stroke, infection, bleeding, myocardial infarction as well as mediastinal wound infection and breakdown.  If we are able to optimize him, hopefully, we can get his operative risk down to 5%.  Thank you very much for allowing us to participate in the care of this pleasant patient.  We will follow along with you.

Cardiac Consult Sample 1   Cardiac Consult Sample 2   Cardiac Consult Sample 3

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