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CLINICAL EXAMPLE 99255
 

 

Cardiology consult for possible unstable angina

Reason for consult : Evaluation and management of possible new onset CHF

Requesting physician : John Doe, MD

HPI : The patient is a 65 year old male is being admitted by his primary physician for chest pain.  He has had intermittent substernal chest pain described as a “squeezing sensation” for approximately two to three weeks.  The pain comes on with exertion and is relieved by rest.  It is sometimes associated with diaphoresis and shortness of breath.  He is chest pain free at the moment.

Medications

Pravachol 40 mg PO QD
HCTZ 25 mg PO QD
Glipizide 5 mg PO QD

PMH : Positive for hypertension, dyslipidemia, diabetes and osteoarthritis controlled with occasional Tylenol.

ROS
General: - Positive for occasional fatigue, negative for fevers or chills
Cardiovascular - Positive mild orthopnea and fluctuating lower extremity edema, negative PND
Pulmonary - Negative for cough, hemoptysis, or pleurisy
GI - Negative for nausea, vomiting, hematemesis, melena

All other systems were reviewed and are negative.

FH : Father died at age 78 of an apparent “old age”.  Mother died of colon cancer in her 70s.  He has three sisters with no known history of heart disease and two grown sons in good health.

SH : Patient quit smoking in 1998 after a 35 pack-year history; drinks two glasses of wine per day.  He lives in a condominium with his wife of 32 years.

Physical Exam

Vitals: 150/84, 92, 98.6
General appearance: NAD, conversant, well nourished white male with normal attention to grooming. Eyes: anicteric sclerae, moist conjunctiva with no lid-lag; PERRLA
HENT: AT/NC; oropharynx clear with moist mucous membranes; normal dentition and gums
Neck: Trachea midline; FROM, supple, no lymphadenopathy, thyromegaly or carotid bruits; no
JVD at 30 degrees. Lungs: CTA in front with bibasilar posterior crackles; normal respiratory effort with no intercostal retractions
CV: RRR, no MRGs, normal non-displaced PMI
Abdomen: Soft, non-tender; no masses or HSM, normal abdominal aorta size and pulsations without bruits
Extremities: Trace bipedal edema with brisk and symmetric pedal pulses; no extremity lymphadenopathy; no digital cyanosis or splinter hemorrhages.
Skin: Normal temperature, turgor and texture; no rash, ulcers or nodules; no levido reticularis
Psych: Appropriate affect, alert and oriented to person, place and time

Labs: Troponins negative times one so far; Glucose 167, BUN 14, creatinine 0.9, K 4.0, HGB 12.4, HCT 36

EKG was reviewed and showed flipped T waves in the lateral leads; no diagnostic ST elevation; LVH by voltage criteria with NSR

Chest X-ray report from the ER was read as “no acute disease”.

Assessment

  1. Chest pain suggestive of unstable angina in patient with multiple cardiac risk factors
  2. NIRDM
  3. Poorly controlled hypertension


Plan

  1. Will arrange for echocardiogram tonight
  2. Remote telemetry
  3. Risks and benefits of cardiac catheterization were discussed with the patient and his wife
  4. The patient already received aspirin in the ER
  5. Nitro paste now; NTG drip if recurrent chest pain this evening
  6. Heparin drip per protocol tonight
  7. Coreg 12.5 mg PO BID

For a detailed breakdown of this note with tips and advice see  99255 E/M Insight

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