Vision Loss Ophthalmology Consult Sample Report

DATE OF CONSULTATION:  MM/DD/YYYY

REFERRING PHYSICIAN:  John Doe, MD

REASON FOR CONSULTATION:  Loss of vision in left eye.

HISTORY OF PRESENT ILLNESS:  This is a (XX)-year-old Hispanic woman who was transferred from an outside hospital where she was admitted with blurry vision.  The patient stated that she was at work, and over a few hours, she lost vision in her left eye.  She could not drive.  She had difficulty walking.  Prior to that, she was having some itching in her eyes for the last one week.  She was taking Flonase.  The patient's friend took her to the hospital where she had to help her walk.  The patient was transferred here for further evaluation.  The patient complained of generalized body ache since yesterday.  She denied any fever.  The patient denied any weakness, numbness in her arms and legs.  She never had these symptoms ever before.  There is no family history of multiple sclerosis.  The patient denied any rash.  She is under stress as her mother is in the hospital with cancer of the lungs.  The patient is able to take care of herself.

PAST MEDICAL HISTORY:  Gastric ulcer.

PAST SURGICAL HISTORY:  None.

SOCIAL HISTORY:  The patient lives with a roommate.  She denied any smoking and alcohol use.

MEDICATION:  Afrin and Percocet.

FAMILY HISTORY:  Cancer.

PHYSICAL EXAMINATION:
GENERAL:  The patient is lying in bed, crying in pain.
HEENT:  Normal.
NECK:  Supple.
LUNGS:  Clear.
HEART:  S1 and S2 normal.
NEUROLOGIC:  Alert and oriented x2.  Speech was normal.  Affect: The patient was constantly crying.  Cranial nerve examination:  The patient had 2 mm dilated pupils, slowly reactive.  Extraocular movements are intact.  She could not count fingers from her left eye.  She had light perception.  She could not recognize the color, and on the right side, she could count fingers.  Rest of the cranial nerve examination was normal.  Motor examination was very difficult to do, as the patient was in extreme pain.  She was extremely tender to touch all over.  Reflexes, 2+ knees, 1+ ankle reflexes, downgoing toes.  Sensory examination was grossly intact.  Coordination:  Gait was not checked due to severe pain.

ASSESSMENT:  This is a (XX)-year-old Hispanic woman who was admitted to the hospital with loss of vision in the left eye.  The patient's neurological examination revealed loss of vision in her left eye to light perception only.  Differential diagnosis includes optic neuritis, but we cannot explain the patient's generalized pain.  We would also keep local eye disease like central retinal artery occlusion in our differential even though we do not think that is the case in her.  Generalized pain is of unclear etiology.  She is under stress.  An MRI of the brain and orbit was normal.  Sedimentation rate is 20.

PLAN:
1.  Visual evoked potentials.  If the patient has evidence of optic neuritis, we will start her on IV steroids.
2.  Pain control.
3.  Ophthalmology consultation.
4.  Motrin.

Thank you, Dr. Doe, for giving us the opportunity to evaluate this pleasant patient.

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Carotid Artery Stenosis Evaluation Consult Sample Report

DATE OF CONSULTATION:  MM/DD/YYYY

REFERRING PHYSICIAN:  John Doe, MD

REASON FOR CONSULTATION:  Evaluation and treatment of carotid artery stenosis.

HISTORY OF PRESENT ILLNESS:  The patient is a (XX)-year-old Hispanic male referred for evaluation of carotid artery stenosis.  During routine workup, a stress test was performed as well as a sonogram of the carotids.  The sonogram of the carotids showed a significant stenosis in the right internal carotid artery.  With these results, an MRA was requested showing arteriosclerosis and narrowing of the proximal right internal carotid artery with a focal high-grade stenosis approximately 1 cm distal to the bifurcation, estimated approximately 90%.  Normal appearance of the left internal carotid artery with bilateral normal vertebral arteries and basilar artery.  The patient is complaining of intermittent dyspnea, no other symptoms.  No symptoms of amaurosis fugax or focalized sensory or motor deficits.

PAST MEDICAL HISTORY:  Positive for hypertension, hyperlipidemia, peptic ulcer disease, gastroesophageal reflux disease, coronary artery disease, and status post myocardial revascularization.  There is no history of diabetes, stroke or cancer.

PAST SURGICAL HISTORY:  Positive for coronary artery bypass graft x3, status post bilateral inguinal hernia repair, status post laparoscopic cholecystectomy, and status post PTCA to coronary arteries.

MEDICATIONS ON ADMISSION:  Zocor, Toprol XL, Norvasc, aspirin, and hydrochlorothiazide.

FAMILY HISTORY:  Positive for coronary artery disease.

SOCIAL HISTORY:  The patient lives by himself and has one daughter.  The patient smoked intermittently, but quit several years ago.

REVIEW OF SYSTEMS:  The patient has had no weight loss or weight gain in the recent past.  No fever in the recent past.  The patient complained of fatigue and occasional dizziness.  The patient wears glasses for reading.  No history of pain, double vision, glaucoma or cataracts.  History of ringing in ears.  No history of vertigo, hoarseness or frequent nosebleed.  No pain urinating, no burning.  The patient describes prostatism with increased frequency and urination at nighttime.  No hematuria.  No history of shortness of breath, no coughing, no wheezing, no persistent cough, and no frequent infections.  No abdominal pain.  No nausea, no vomiting, no heartburn.  No upper or lower GI bleeds.  The patient complains of intermittent constipation.  Positive for chest pain and palpitations.  No abnormal bleeding or hypercoagulable state.  The patient is complaining of stiffness and muscle pain in the upper and lower extremity.  No seizures or memory loss.  No CVAs.  No loss of consciousness.  No rashes or sores.  No itching, no burning of the skin.

PHYSICAL EXAMINATION:
VITAL SIGNS:  The patient is afebrile, pulse 66, respirations 18, and blood pressure 154/82.
GENERAL APPEARANCE:  The patient is awake, alert, oriented, in no acute distress.  Well nourished and well developed.
HEENT:  Head is normocephalic and atraumatic.  No sinus or mastoid tenderness.  Pupils are equal and reactive to light and accommodation.  Extraocular muscle movements are intact.  The oropharynx is clear.  Oral mucosa is pink and moist.
NECK:  Supple and symmetrical.  No jugular vein distention.  No thyromegaly, no lymphadenopathy.  The patient has a right carotid bruit.
CHEST:  Symmetrical with a surgical scar from the previous bypass surgery.
LUNGS:  Decreased breath sounds on both bases, but the lungs are clear.  No wheezes, rales or crackles.
HEART:  Shows a regular rate and rhythm.  S1 and S2.  No murmurs, rubs, or gallops.
ABDOMEN:  Soft, nontender.  Bowel sounds are present.  No visceromegaly, no palpable masses, no detectable bruits, no guarding or peritoneal signs.  Surgical scar from a previous procedure.
EXTREMITIES:  No edema, cyanosis, clubbing or joint swelling.  No calf pain.
VASCULAR:  Peripheral pulses are present in all extremities with good capillary refill.
NEUROLOGICAL:  No gross motor or sensory deficits.  The patient is awake, alert, and oriented x3.

DIAGNOSTIC TESTS:  MRA, as previously described in the history of present illness.  EKG shows a normal sinus rhythm with left atrial enlargement.  Anterolateral T-wave abnormalities.

LABORATORY TESTS:  White blood count 5.6, hemoglobin 15.6, hematocrit 45.4, and platelets 154,000.  PT 13.4, PTT 29.8.  Sodium 140, potassium 3.5, chloride 98, CO2 of 26, glucose 92, BUN 16, and creatinine 1.1.  Total protein 8.6, albumin 4.8, magnesium 1.8.  Urinalysis within normal limits.

IMPRESSION:
1.  Severe right internal carotid artery stenosis.
2.  Arterial disease.
3.  Status post coronary artery bypass graft surgery.
4.  Hypertension.
5.  Dyslipidemia.
6.  Gastroesophageal reflux disease.

PLAN:  With the previous information, the patient has an asymptomatic severe right carotid artery stenosis; its treatment option is carotid endarterectomy.  Risks and possible complications were explained to the patient as well as treatment options.  The patient agrees with the procedure and will proceed with a right carotid endarterectomy.  We will do intraoperative EEG evaluation as well as a cerebral oximetry during the operative procedure.  The patient agrees.

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

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Congestive Heart Failure Consult Sample Report

DATE OF CONSULTATION:  MM/DD/YYYY

REFERRING PHYSICIAN:  John Doe, MD

HISTORY OF PRESENT ILLNESS:  The patient is a (XX)-year-old Hispanic male, who was transferred for hypotension. Medical history is from review of the medical record and nursing home records, as the patient is unable to provide a significant amount of information. The patient was transferred from the nursing home for several days of generalized weakness and was noted to be hypotensive in the nursing home. The nursing home records reflect that the patient has had a new cough with green sputum, though he, over the past few days, has had decreased breath sounds and crackles, right more than left, with a few expiratory wheezes as well. He has not had a documented fever in the nursing home. He was treated in the nursing home for bronchitis with Biaxin, mucolytics, Robitussin, and was started on Bumex for venostasis disease. The patient was admitted today with hypotension. In the ambulance, his systolic blood pressure was approximately 80 while in the emergency department his systolic blood pressures in both arms were in the 60s. He was given approximately 2 liters of fluid during his time in the ER and atropine and was started on a dopamine drip. His initial EKG demonstrated sinus rhythm with a ventricular rate of approximately 44 beats per minute with a prolonged PR interval though no evidence of acute ischemic events. No ST segment abnormalities.

PAST MEDICAL HISTORY:  COPD, for which the patient takes prednisone on every-other-day basis, diabetes mellitus, hypertension, benign prostatic hypertrophy, chronic renal insufficiency, and sick sinus syndrome.

MEDICATION ALLERGIES:  NKDA.

SOCIAL HISTORY:  Unknown whether or not the patient is a smoker or a drinker, and it is unknown what the patient's prior occupation was.

FAMILY HISTORY:  Noncontributory.

CURRENT MEDICATIONS:  In the nursing home include Mucinex, Bumex, Tylenol as needed, Biaxin, Colace, glyburide 10 mg twice daily, fluticasone nasal spray, GlycoLax, metformin 500 mg twice daily, multivitamins, lisinopril 2.5 mg daily, Flomax, Lasix, loratadine, Aldactone 25 mg daily, Toprol-XL 50 mg daily, Zocor 20 mg daily, NovoLog, prednisone 10 mg 3 times a week on Monday, Wednesday, and Friday.

REVIEW OF SYSTEMS:  From the medical record indicates no constitutional symptoms, no fever, no chills, although he does report weakness. He denies shortness of breath or recent chest pain or pleuritic chest pain. He denies recent syncope. The patient had a recent echocardiogram, which demonstrated an ejection fraction of 65% with an increased LV size, mitral valve leaflets with normal motion, but mild left atrial dilatation, RA and RV with normal size and unremarkable IVC, though he had mild TR and an estimated right ventricular systolic pressure of 53 mmHg and was interpreted as mild diastolic dysfunction with mild-to-moderate pulmonary hypertension.

PHYSICAL EXAMINATION:
VITAL SIGNS:  The patient's vital signs upon arrival to the intensive care unit are blood pressure of 120/56, heart rate ranging from 50 to 68 with sinus rhythm, respiratory rate approximately 22 times per minute, and a temperature of 95.6 degrees.
GENERAL:  The patient is sleepy and lethargic, though is arousable and does answer questions for a brief period when prompted to do so. He does follow commands until he falls asleep.
HEART:  The patient has a regular rate and rhythm. S1 and S2 are appreciated.
LUNGS:  There are diffuse bilateral crackles in the posterior lung fields. Also heard are bilateral expiratory wheezes with a few scattered inspiratory squeaks.
ABDOMEN:  Soft and nontender.
EXTREMITIES:  Display significant symmetric lower extremity edema, 3+ bilaterally, as well as erythematous, warm lesions to both anterior legs consistent with cellulitis.

LABORATORY AND DIAGNOSTIC DATA:  Demonstrates blood gas with pH of 7.34, pCO2 of 50.6, and pO2 of 57.8. Chemistry with a sodium of 135, potassium 4.2, chloride 100, CO2 of 30, BUN 54, creatinine 2.0, and glucose of 62. Albumin is 2.5. Total bilirubin is 0.4. Magnesium is 2.6. Troponin is less than 0.4, and BNP is 106. INR is 0.92. White count is 10.8, hemoglobin is 12.4, hematocrit is 38.6, and platelets are 184. Urinalysis, urine cultures, and blood cultures are pending at this time. A chest x-ray was done in the emergency department demonstrating pulmonary vascular congestion and a widened mediastinum on this portable view. He had a CAT scan done in the past demonstrating wide mediastinum due to mediastinal lipomatosis, though he had a prominent ascending thoracic arch at that time, which measured 4.2 cm as well.

ASSESSMENT:  This gentleman has a congestive heart failure and chronic obstructive pulmonary disease exacerbation in the setting of an infection, possibly cellulitis, possibly urinary tract infection complicated by excessive beta blockade.

PLAN:  We will treat his CHF exacerbation with intermittent doses of loop diuretics and with CPAP 6 cm of water pressure. We will treat his underlying infection, which likely include cellulitis and possibly an urinary tract infection, with cefepime which he has already received in the emergency department and vancomycin to cover resistant gram positive, which may be responsible for his cellulitis. We will obtain a CAT scan of his chest to evaluate the mediastinal widening in the presence of a known ascending thoracic arch prominence on a prior CAT scan and low blood pressure. We will hold metformin and oral diabetes medications and instead place him on an insulin sliding scale. We will treat his COPD exacerbation with albuterol and Atrovent nebulizers and increase his steroids to Solu-Medrol 40 mg q. 8 hours IV. The patient is currently not bradycardic, though if bradycardia persists despite dobutamine, we will initiate therapy with glucagon to reverse beta blockade. The patient likely suffers from obstructive sleep apnea, as he is noted to have a thick neck and is obese and was noted to be snoring. We will prescribe empiric CPAP therapy for the presumed diagnosis of sleep apnea, as well as for a CHF exacerbation.

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

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