CAROLINA'S CARDIOLOGY/EP  CONSULTATION

Was asked to see Mr.

History Of Present Illness
Mrs

Past Medical History
1.  


Past Surgical History
1.

Family History
Negative for premature CAD, CHF, PPM, or sudden cardiac death


Social History
Never a smoker. Denies alcohol or drug use.

Allergies
NKDA


ROS
Constitutional:
no fever, no chills, no cold sweats, no weakness, no fatigue, no decreased activity.
Ear/Nose/Mouth/Throat: No decreased hearing, No ear pain, No nasal congestion, No sore throat.
Respiratory: no shortness of breath, No cough, No sputum production, No hemoptysis, No wheezing, No
cyanosis.
Cardiovascular: No chest pain, no palpitations, no peripheral edema, No syncope.
Gastrointestinal: No nausea, No vomiting, No diarrhea, No constipation, No heartburn, No abdominal pain.
Genitourinary: No dysuria, No hematuria, No change in urine stream, No urethral discharge, No lesions.
Hematology/Lymphatics: No bruising tendency, No bleeding tendency, No petechiae, No swollen lymph
glands.
Endocrine: No excessive thirst, No polyuria, No cold intolerance, No heat intolerance, No excessive hunger.
Integumentary: No rash, No pruritus, No abrasions.
Neurologic: Alert and oriented x2. Decreased motor function LUE and LLE
Psychiatric: No anxiety, No depression, No mania.  


Physical Exam
Vital Signs

General: cachectic, lethargic but arousable, non verbal. Dry mucosa
Neck: Trachea midline, no masses.
No carotid bruit, JVP non elevated <3 cm H2O. Carotid upstrokes
preserved 2+ bilaterally
Respiratory: normal chest wall expansion, normal B/S bilaterally. No wheezes or rhonchi. No rales
Cardiovascular: RRR S1 S2 distinctly audible, no extra heart sound, no rubs. No murmur.
Abdomen: Obese, Soft, non-tender, non-distended, normal bowel sounds in all quadrants, No
hepatomegaly, no ascites, no abdominal bruit or thrill, no renal bruit.
Rectal: deferred
Musculoskeletal: normal ROM in upper and lower extremities.
Dorsalis Pedis pulses 2+ bilaterally
Integumentary: warm, dry, and pink, with no rash, purpura, or petechia
Heme/Lymph: no lymphadenopathy, no bruises. RLE amputated,
LLE no edema
Neurological: 2+ patellar reflexes, Cranial Nerves II-XII grossly intact, no tics, normal sensation to pressure
and light touch
Psychiatric: cooperative with normal mood, affect, and cognition  


Medications Active


Home Medications

EKG

Labs

ECHO

STRESS



IMPRESSION
1-



Thank you for this consult. I will continue following with you through this hospitalization. Please do not
hesitate to contact me with any questions.