Sample Type / Medical Specialty: Cardiovascular / Pulmonary Sample Name: Cardiomyopathy & Hypotension - Consult Description: Cardiomyopathy and hypotension. A lady with dementia, coronary arte ry disease, prior bypass, reduced LV function, and recurrent admissions for diar rhea and hypotension several times. (Medical Transcription Sample Report) REASON FOR CONSULTATION: Cardiomyopathy and hypotension. HISTORY OF PRESENT ILLNESS: I am seeing the patient upon the request of Dr. X. T he patient is very well known to me, an 81-year-old lady with dementia, a native American with coronary artery disease with prior bypass, reduced LV function, r ecurrent admissions for diarrhea and hypotension several times in November and w as admitted yesterday because of having diarrhea with hypotension and acute rena l insufficiency secondary to that. Because of her pre-existing coronary artery d isease and cardiomyopathy with EF of about 30%, we were consulted to evaluate th e patient. The patient denies any chest pain or chest pressure. Denies any palpi tations. No bleeding difficulty. No dizzy spells. REVIEW OF SYSTEMS: CONSTITUTIONAL: No fever or chills. EYES: No visual disturbances. ENT: No difficulty swallowing. CARDIOVASCULAR: Basically, no angina or chest pressure. No palpitations. RESPIRATORY: No wheezes. GI: No abdominal pain, although she had diarrhea. GU: No specific symptoms. MUSCULOSKELETAL: Have sores on the back. NEUROLOGIC: Have dementia. All other systems are otherwise unremarkable as far as the patient can give me i nformation. PAST MEDICAL HISTORY: 1. Positive for coronary artery disease for about two to three years. 2. Hypertension. 3. Anemia. 4. Chronic renal insufficiency. 5. Congestive heart failure with EF of 25% to 30%. 6. Osteoporosis. 7. Compression fractures. 8. Diabetes mellitus. 9. Hypothyroidism. PAST SURGICAL HISTORY: 1. Coronary artery bypass grafting x3 in 2008. 2. Cholecystectomy. 3. Amputation of the right second toe. 4. ICD implantation. CURRENT MEDICATIONS AT HOME: 1. Amoxicillin. 2. Clavulanic acid or Augmentin every 12 hours. 3. Clopidogrel 75 mg daily. 4. Simvastatin 20 mg daily. 5. Sodium bicarbonate 650 mg twice daily. 6. Gabapentin 300 mg. 7. Levothyroxine once daily. 8. Digoxin 125 mcg daily. 9. Fenofibrate 145 mg daily.
