Sample Type / Medical Specialty: Cardiovascular / Pulmonary

Sample Name: Cardiac Consultation - 7

Description: The patient has a previous history of aortic valve disease, status
post aortic valve replacement, a previous history of paroxysmal atrial fibrillat
ion, congestive heart failure, a previous history of transient ischemic attack w
ith no residual neurologic deficits.
(Medical Transcription Sample Report)
HISTORY OF PRESENT ILLNESS: The patient is a 41-year-old African-American male p
reviously well known to me. He has a previous history of aortic valve disease, s
tatus post aortic valve replacement on 10/15/2007, for which he has been on chro
nic anticoagulation. There is a previous history of paroxysmal atrial fibrillati
on and congestive heart failure, both of which have been stable prior to this ad
mission. He has a previous history of transient ischemic attack with no residual
neurologic deficits.
The patient has undergone surgery by Dr. X for attempted nephrolithotomy. The pa
tient has experienced significant postoperative bleeding, for which it has been
necessary to discontinue all anticoagulation. The patient is presently seen at t
he request of Dr. X for management of anticoagulation and his above heart diseas
e.
PAST MEDICAL AND SURGICAL HISTORY:
1. Type I diabetes mellitus.
2. Hyperlipidemia.
3. Hypertension.
4. Morbid obesity.
5. Sleep apnea syndrome.
6. Status post thyroidectomy for thyroid carcinoma.
REVIEW OF SYSTEMS:
General: Unremarkable.
Cardiopulmonary: No chest pain, shortness of breath, palpitations, or dizziness.
Gastrointestinal: Unremarkable.
Genitourinary: See above.
Musculoskeletal: Unremarkable.
Neurologic: Unremarkable.
FAMILY HISTORY: There are no family members with coronary artery disease. His mo
ther has congestive heart failure.
SOCIAL HISTORY: The patient is married. He lives with his wife. He is employed a
s a barber. He does not use alcohol, tobacco, or illicit drugs.
MEDICATIONS PRIOR TO ADMISSION:
1. Clonidine 0.3 mg b.i.d.
2. Atenolol 50 mg daily.
3. Simvastatin 80 mg daily.
4. Furosemide 40 mg daily.
5. Metformin 1000 mg b.i.d.
6. Hydralazine 25 mg t.i.d.
7. Diovan 320 mg daily.
8. Lisinopril 40 mg daily.
9. Amlodipine 10 mg daily.
10. Lantus insulin 50 units q.p.m.
11. KCl 20 mEq daily.
12. NovoLog sliding scale insulin coverage.
13. Warfarin 7.5 mg daily.
14. Levothyroxine 0.2 mg daily.

15. Folic acid 1 mg daily.

ALLERGIES: None.
PHYSICAL EXAMINATION:
General: A well-appearing, obese black male.
Vital Signs: BP 140/80, HR 88, respirations 16, and afebrile.
HEENT: Grossly normal.
Neck: Normal. Thyroid, normal. Carotid, normal upstroke, no bruits.
Chest: Midline sternotomy scar.
Lungs: Clear.
Heart: PMI fifth intercostal space mid clavicular line. Normal S1 and prosthetic
S2. No murmur, rub, gallop, or click.
Abdomen: Soft and nontender. No palpable mass or hepatosplenomegaly.
Extremities: Normal. No edema. Pulses bilaterally intact, carotid, radial, femor
al, and dorsalis pedis.
Neurologic: Mental status, no gross cranial nerve, motor, or sensory deficits.
ELECTROCARDIOGRAM: Normal sinus rhythm. Right bundle-branch block. Findings comp
atible with old anteroseptal and lateral wall myocardial infarction.
_______ nonspecific ST-T abnormality.
IMPRESSION:
1. Status post nephrolithotomy with postoperative hematuria.
2. Aortic valve disease, status post aortic valve replacement on 10/15/2007.
3. Congestive heart failure, diastolic, chronic, stable, NYSHA class I to II.
4. Paroxysmal atrial fibrillation.
5. Status post remote transient ischemic attack with no residual neurologic defi
cits.
6. Type I diabetes mellitus.
7. Hyperlipidemia.
8. Hypertension.
9. Morbid obesity.
10. Sleep apnea syndrome.
11. Chronic therapeutic anticoagulation.
RECOMMENDATIONS: Until resolution of the hematuria, I agree with the necessity o
f discontinuation of all anticoagulation. There is obvious risk both due to pros
thetic aortic valve and paroxysmal atrial fibrillation with continuation of anti
coagulation; however, the risk of uncontrolled bleeding is essentially worse.
Continue other medications.
Keywords: cardiovascular / pulmonary, aortic valve disease, aortic valve replace
ment, anticoagulation, paroxysmal atrial fibrillation, congestive heart failure,
neurologic deficits, atrial fibrillation, aortic valve, heart, ischemic, atrial
, neurologic, aortic, valve, disease,