REASON FOR CONSULTATION:
Cardiology.

REFERRING PHYSICIAN:
George Washington, M.D.

CONSULTING PHYSICIAN:
Abraham Lincoln, M.D., F.A.C.C.

HISTORY OF PRESENT ILLNESS:
The patient is an 82-year-old female who was admitted from the nursing home with respiratory failure. The patient has had a recent history of a non-Q wave myocardial infarction with subsequent balloon intervention to the ramus branch with stenting and good results. She also had, at that time, a sick sinus conduction system disease with paroxysmal arrhythmia and tachycardia/bradycardia type symptomatology with ultimately the placement of a permanent pacemaker. It was a sequential type Integrity AFXDR, Model # 5346. The patient did well in the nursing home until the day when she presented to the emergency room with pulmonary edema. She was intubated and was subsequently stabilized.

MEDICATIONS:
The patient had been on some amiodarone in the nursing home at 200 mg b.i.d. Also, she was on Demadex 100 mg one-half tablet daily, Amaryl 2 mg daily, Coumadin daily, Humulin 70/30 insulin mixture at 30 units in the a.m. and 25 units p.m., potassium 20 mEq daily, Tegretol 200 mg t.i.d., Altace 2.5 mg daily, calcium carbonate one tablet daily, aspirin 325 mg p.o. daily, isosorbide mononitrate 30 mg daily, Diltiazem XR 240 mg daily, Toprol XL 50 mg daily, and prednisone 10 mg daily. It is unclear as to why she was taken off of her Plavix, but she was to continue on the Plavix in light of her recent stent placement.

The patient was treated with Solu-Medrol in the emergency room and was given Lasix 40 mg intravenously and was placed on a low dose of dopamine at 3 mcg/kg per minute and 5 mcg of intravenous nitroglycerin.

PHYSICAL EXAMINATION: Currently:
GENERAL APPEARANCE: When awake, she is somewhat combative. She is currently sedated on Diprivan.
VITAL SIGNS: Blood pressure 140/60. Recheck seemed to stay in the range of 110-140. The initial rhythm of her heart was 139 which is clearly a pacemaker mediated tachycardia. The pacemaker was subsequently reprogrammed with immediate resolution of that tachycardia.
NECK: Jugular venous pressure appears to be normal.
LUNGS: On the ventilator, the lungs demonstrate to be fairly clear.
HEART: Demonstrates S1 less than S2. No S3 is noted.
ABDOMINAL EXAMINATION: Obese and fine to examination.
EXTREMITIES: No edema.

LABORATORY DATA:
Cardiac enzymes reveal: Mild troponin level bump is noted at 0.20. Myoglobin assay 92.8. CK-MB 4.5 (normal less than 4.1). Total CPK, however, is 42. Hemoglobin and hematocrit are 11 and 34. White blood cell count 13,000. Platelet count 290,000. BUN 33. Creatinine 1.7. Glucose 317. Potassium 4.0. Magnesium 4.7. Phosphorus 4.2.

ASSESSMENT:
The cardiac status at this point appears to be more stable with the rhythm potentially improving her pulmonary status. I suspect this whole scenario is related to tachyarrhythmia and that currently, hopefully, with the reprogramming, this will be a thing of the past. Meanwhile, there are severe other medical problems including the chronic obstructive pulmonary disease, the diabetes mellitus, hypertensive heart disease. These will be stabilized.

Thanks so much for allowing us to share in her management. Will follow as needed.

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