DATE OF OPERATION: MM/DD/YYYY
REFERRING PHYSICIAN: John Doe, MD
REASON FOR CONSULTATION: Elevated troponin.
HISTORY OF PRESENT ILLNESS: This is a pleasant (XX)-year-old African-American male with a past medical history significant for diabetes mellitus type 2, hypertension, right lower extremity deep venous thrombosis, and HIV who presented to the emergency department via EMS yesterday evening with complaints of chest pain and shortness of breath. The patient was recently discharged from the hospital with final diagnosis of urinary tract infection; acute renal failure, resolved; non-insulin-dependent diabetes; and deep venous thrombosis of his right lower extremity. He was subsequently readmitted and then discharged again with HIV and primary discharge diagnosis of pneumonia, probably secondary to aspiration. The patient was doing well since that time until yesterday afternoon. While his brother was trying to sit him up from bed, he became acutely short of breath and had left-sided chest pain, which lasted 2 minutes before resolving spontaneously. The brother stated that the patient fell back, although denied seeing any seizure-like activity or syncopal episode. The patient is unable to describe the quality or severity of his pain. The patient states that the pain resolved spontaneously after a couple of minutes, and he felt back to his baseline. The brother was concerned and called 911, who arrived at the scene and noted that the patient had a blood pressure of 110/58, pulse of 76, and respiratory rate of 20.
He was transported to the emergency department for further evaluation and management. Upon arrival to the emergency department, his oxygen saturations were 98% on 2 liters nasal cannula. His blood pressure was 106/70, pulse of 88, respiratory rate of 18, and temperature of 98.6. A 12-lead EKG was obtained, which demonstrated normal sinus rhythm, rate 88 with diffuse ST-T abnormalities with possible ischemia. The patient had an episode in the emergency department in the evening, where he had decreased systolic blood pressure of 82 mmHg. At that time, the patient stated he had pain in his leg, according to the emergency department record, and he was given a fluid bolus. His blood pressure increased to low 100 systolic. The patient had a V/Q scan of the lungs, which returned as high probability for pulmonary embolism, and he subsequently had CTA of the chest, which demonstrated bilateral pulmonary embolism, right upper and lower lobe infiltrates and prominent cardiac silhouette. The patient has had an elevated troponin level of 0.58, and he was admitted to the PCU for further workup, and cardiac consult was requested.
The patient denies any diaphoresis, headache, diplopia, blurred vision, cough, dyspnea on exertion, palpitations, orthopnea, paroxysmal nocturnal dyspnea, pedal edema, weight gain, nausea, vomiting, hematemesis, genitourinary frequency, dizziness or syncope. The patient states that he did not have right lower extremity pain or swelling prior to his admission. The patient is currently being followed by his primary care physician, who is managing his PT/INR. According to the brother, he has had difficulty stabilizing the INR in a therapeutic range.
PAST MEDICAL HISTORY: Significant for diabetes mellitus type 2, hypertension, right lower extremity deep venous thrombosis, cerebrovascular accident, HIV, neuropathy, sepsis, and pneumonia.
PAST SURGICAL HISTORY: Significant for back surgery.
HOME MEDICATIONS: Include Altace, Diovan, Aldactone, Lipitor, Keppra, Prevacid, dapsone, Epivir, Coumadin, Ziagen, Lexapro, and hydrocodone.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: The patient denies any tobacco or illicit drug use. He is currently disabled and lives with his brother. He is divorced and has two children.
FAMILY HISTORY: Significant for diabetes. Otherwise, denies family history of coronary artery disease, hypertension, myocardial infarction or cerebrovascular accident.
REVIEW OF SYSTEMS: A 14-point review of systems was completed with the patient and is negative unless mentioned in the HPI.
PHYSICAL EXAMINATION:
GENERAL: This is a pleasant (XX)-year-old African-American male, lying in bed, and in no acute physical distress.
VITAL SIGNS: Blood pressure is 114/64, heart rate is 90, respiratory rate is 18, temperature is 97.4, and oxygen saturations are 91% on room air.
HEENT: Atraumatic and normocephalic. Pupils are equal, round, reactive to light and accommodation. Oral mucosa is pink and moist.
NECK: Supple. Trachea is midline. No JVD, carotid bruits or thyromegaly is noted.
LUNGS: Clear throughout, although somewhat diminished in bilateral bases.
HEART: S1 and S2. No S3, S4, rub or murmur appreciated.
ABDOMEN: Positive bowel sounds in all quadrants, soft, and rounded. No masses or tenderness are noted.
PERIPHERAL: Pulses +2 in all extremities. No clubbing, cyanosis or edema noted. Homans sign negative bilaterally.
NEUROLOGIC: Cranial nerves II through XII are grossly intact.
LABORATORY DATA: Sodium 134, potassium 4.2, chloride 104, CO2 of 24, BUN 32, creatinine 0.8, glucose 82, calcium 9.2, and magnesium 1.5. White blood cell count 21.2, hemoglobin 9.6, hematocrit 28.6, and platelets 334,000. PT 18.6, PTT 33.2, INR 1.56, troponins 0.58, 0.36, 0.22, and CK-MBs were negative x3. ALT 76, AST 42. LFTs were otherwise within normal limits.
DIAGNOSTIC TESTING: A 12-lead EKG completed on arrival to the emergency department demonstrates normal sinus rhythm with rate of 88 beats per minute with diffuse ST-T abnormalities, possible ischemia. Chest x-ray showed improvement of the right upper lobe infiltrates since prior exam. V/Q scan was high probability for pulmonary embolism. CTA of the chest demonstrated bilateral pulmonary embolism, right upper lobe and right lower lobe infiltrate and prominent cardiac silhouette.
IMPRESSION:
1. Bilateral pulmonary embolism.
2. Chest pain, atypical, probably secondary to bilateral pulmonary embolism.
3. Slightly elevated troponin level of 0.58, probably secondary to bilateral pulmonary embolism.
4. History of right lower extremity deep venous thrombosis.
5. Subtherapeutic anticoagulation therapy with INR of 1.56.
6. Hypertension, controlled.
7. Human immunodeficiency virus.
8. History of cerebrovascular accident.
9. History of nephropathy, sepsis, and pneumonia.
10. Anemia.
11. Leukocytosis.
PLAN:
1. Continue telemetry monitoring.
2. A 2-D echocardiogram.
3. Anticoagulation therapy.
4. Continue Diovan, Altace, and spironolactone.
5. Further recommendations will depend on the results of the above.
