Cardiology Consult for Dr. Anya Sharma, Cardiologist
Reason for Consultation:
Patient presenting with acute chest pain and shortness of breath. Referred from the Emergency Department for evaluation of possible cardiac etiology.
History of Present Illness:
Patient, a 68-year-old male, reports sudden onset of severe, crushing chest pain radiating to the left arm, which began approximately 2 hours prior to presentation. Associated symptoms include shortness of breath, diaphoresis, and nausea. The pain has not been relieved by rest or sublingual nitroglycerin.
Cardiac History:
- History of hypertension
- Previous myocardial infarction 5 years ago
- Underwent percutaneous coronary intervention (PCI) with stent placement in the left anterior descending artery (LAD)
PMHx:
- Hypertension
- Hyperlipidemia
- Type 2 Diabetes Mellitus
Meds:
- Aspirin 81mg daily
- Metoprolol 50mg twice daily
- Lisinopril 20mg daily
- Atorvastatin 40mg daily
- Insulin glargine 10 units subcutaneously at bedtime
FHx:
- Father: History of coronary artery disease, died at age 70
- Mother: History of hypertension
Social:
- Smoker: 1 pack per day for 40 years
- Alcohol: Occasional use
- Exercise: Sedentary lifestyle
- Occupation: Retired accountant
O/E:
- BP: 160/90 mmHg, HR: 110 bpm, RR: 24 breaths/min, SpO2: 92% on room air
- General: Appears acutely ill, in distress
- Cardiovascular: S1 and S2 present, no murmurs, rubs, or gallops. Elevated JVP.
- Lungs: Bilateral crackles in the bases.
Ix:
- ECG: ST-segment elevation in leads II, III, and aVF.
- Cardiac enzymes: Elevated troponin I.
- Chest X-ray: Mild pulmonary congestion.
Impression:
Acute ST-elevation myocardial infarction (STEMI).
Plan:
- Immediate transfer to the cardiac catheterization lab for emergent PCI.
- Administer oxygen, aspirin, and heparin.
- Continue monitoring of vital signs and cardiac rhythm.
- Cardiology to manage post-procedure.
- Follow up in cardiology clinic in 2 weeks.
- Patient education on lifestyle modifications, including smoking cessation and dietary changes.
- Discussed the need for cardiac rehabilitation.
Cardiology Consult for Dr [insert name of cardiologist on call] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.), Cardiologist
Reason for Consultation:
[describe the reason for the cardiology consultation, including any specific symptoms, concerns, or referral details] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
History of Present Illness:
[detail the history of the presenting illness, including onset, duration, progression, and any associated symptoms] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
Cardiac History:
[document information regarding previous cardiac disease, concerns, interventions, and investigations] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. List in bullet points with "-".)
PMHx:
[document past medical history, including any previous cardiovascular conditions, surgeries, and other relevant medical conditions] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. List in bullet points with "-".)
Meds:
[list current medications, including dosages, frequency, and any over-the-counter supplements] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. List in bullet points with "-".)
FHx:
[describe any family history of cardiovascular diseases or other relevant medical conditions] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. List in bullet points with "-".)
Social:
[document social history, including smoking status, alcohol consumption, exercise habits, and occupation] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. List in bullet points with "-".)
O/E:
[document findings from the physical examination, including vital signs, cardiovascular examination, and any other relevant systems] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. List in bullet points with "-".)
Ix:
[list any investigations ordered or reviewed, including blood tests, imaging studies, and other diagnostic tests] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. List in bullet points with "-".)
Impression:
[provide an assessment of the patient’s condition, including differential diagnoses and clinical impressions] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
Plan:
[outline the management plan, including any medications prescribed, lifestyle modifications, follow-up appointments, and referrals to other specialists] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. List in bullet points with "-".)
[detail the follow-up plan, including the timing of the next appointment and any specific instructions for the patient] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. List in bullet points with "-".)
(Never come up with your own patient details, assessment, plan, interventions, evaluation, and plan for continuing care - use only the transcript, contextual notes or clinical note as a reference for the information included in your note. If any information related to a placeholder has not been explicitly mentioned in the transcript, contextual notes or clinical note, you must not state the information has not been explicitly mentioned in your output, just leave the relevant placeholder or omit the placeholder completely.) (Use as many lines, paragraphs or bullet points with "-", depending on the format, as needed to capture all the relevant information from the transcript.) information from the transcript.)