RG Consult Note

plaintext =========================== HISTORY OF PRESENT ILLNESS =========================== Mr. John Smith, [age 78] and male, with a history of hypertension, hyperlipidemia, and coronary artery disease (status post-PCI 2018) presented with worsening shortness of breath and chest pain. He was found to have atrial fibrillation (CHADSVASC score 3, on apixaban 5mg BID) and heart failure with reduced ejection fraction (HFrEF, EF 35%). He was admitted to the hospital for management of his heart failure exacerbation. Patient reports chest pain described as a pressure-like sensation, radiating to the left arm, lasting for approximately 30 minutes, and occurring at rest. Shortness of breath has been present for the past week, progressively worsening. Symptoms are exacerbated by exertion and relieved by rest and sublingual nitroglycerin. Patient reports similar episodes of chest pain in the past, managed with nitroglycerin. Patient reports that the symptoms are affecting his ability to walk and perform daily activities. Patient also reports mild lower extremity edema. ================================================== MEDICATIONS AND ADDITIONAL PAST MEDICAL HISTORY ================================================== CURRENT MEDICATIONS: - Metoprolol 25mg BID - Lisinopril 10mg daily - Apixaban 5mg BID - Atorvastatin 20mg daily - Furosemide 40mg daily RELEVANT HOME MEDICATIONS: - Metoprolol 25mg BID - Lisinopril 10mg daily - Apixaban 5mg BID - Atorvastatin 20mg daily - Furosemide 40mg daily CARDIOVASCULAR CONDITIONS: - Coronary Artery Disease (status post-PCI 2018) - Atrial Fibrillation (CHADSVASC score 3, on apixaban 5mg BID) - Heart Failure with reduced ejection fraction (HFrEF, EF 35%) - Hypertension OTHER NON-CARDIAC CONDITIONS: - Hyperlipidemia - Type 2 Diabetes Mellitus RELEVANT FAMILY AND SOCIAL HISTORY: - Lives at home with his wife. - Denies tobacco, alcohol, or illicit drug use. - Walks with a cane. - Family history of coronary artery disease. ========================================== VITALS AND PHYSICAL EXAMINATION FINDINGS ========================================== VITAL SIGNS: T 100.2, HR 110, RR 20, BP 140/90, SpO2 94% on 2L nasal cannula. PHYSICAL EXAMINATION: - General: Appears in mild distress. - HEENT: Normocephalic, atraumatic. - Cardiovascular: Tachycardic, irregular rhythm, no murmurs, rubs, or gallops. - Pulmonary: Bilateral crackles at the bases. - Abdominal: Soft, non-tender, non-distended. - Neurologic: Alert and oriented to person, place, and time. - Musculoskeletal: Mild lower extremity edema. - Skin: Warm and dry. ================================================== LABS, IMAGING, AND RELEVANT CARDIOVASCULAR DATA ================================================== LABS: - Troponin elevated. - BNP elevated. ECG: - Atrial fibrillation with rapid ventricular response. ECHOCARDIOGRAM: - EF 35%. =================================== ASSESSMENT AND RECOMMENDATIONS =================================== ACTIVE CARDIOLOGY PROBLEM(S): 1. Worsening shortness of breath and chest pain. ASSESSMENT: Mr. Smith, a 78-year-old male with a history of coronary artery disease, atrial fibrillation, and heart failure with reduced ejection fraction, presented with worsening shortness of breath and chest pain for which cardiology was consulted. The patient's presentation is concerning for an acute coronary syndrome and heart failure exacerbation. RECOMMENDATIONS: # Acute Coronary Syndrome - Obtain serial cardiac enzymes. - Consider emergent cardiac catheterization. - Continue aspirin and statin. # HFrEF exacerbation - Continue IV furosemide. - Optimize guideline-directed medical therapy. - Monitor daily weights and urine output. - Consider discharge to home with close follow-up.