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CARDIOLOGY
CONSULTION-3
REASON FOR REFERRAL: Cardiac evaluation. HISTORY OF PRESENT ILLNESS: This is a 56-year-old female with history of hypertension, hyperlipidemia, chronic renal insufficiency and paroxysmal atrial fibrillation with history of transient ischemic attack in 1995, referred for cardiac evaluation. The patient complains of occasional numbness in the arms. She denied any history of chest pain. She has a history of mild shortness of breath. She denied any history of hypertension. SOCIAL HISTORY: She is not a smoker. PHYSICAL EXAMINATION: She is in no acute distress. BP is 90/60 mmHg. No JVD. No carotid bruits. Lungs are clear to auscultation. Heart is regular with ejection systolic murmur grade 2/6. The abdomen is unremarkable. There is no ankle edema. The pulses are equal bilaterally. ECHOCARDIOGRAM: EKG shows normal sinus rhythm at the rate of 48 beats per minute, otherwise normal. An echocardiographic examination was performed. The left ventricle shows normal dimensions with normal wall motion and contractility. The left ventricular ejection fraction is normal. The estimated left ventricular ejection fraction is 60%. The atria and right ventricle are normal. There is no pericardial effusion. The aortic root diameter is normal. The aortic, mitral, and tricuspid valves show normal morphology. There is mild aortic valve calcification. Intracardiac Doppler reveals mild aortic insufficiency. The study is of fair quality. IMPRESSION: OPINION & RECOMMENDATIONS: The patient
should be started on Plavix 75 mg p.o. q.d. in view of the history of
paroxysmal atrial fibrillation and TIA. The patient should have a neurological
evaluation. An MRI of the head is recommended. The patient will also undergo
a 24-hour Holter monitor to evaluate for paroxysmal atrial fibrillation.
In view of the low blood pressure, I have advised the patient to stop
the lisinopril. The patient will continue with Corgard 20 mg p.o. q.d.
and Pravachol 40 mg p.o. q.d. I will forward the results of the Holter
monitor as soon as it is done. |
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