Cardiac Consultation - 6 

INDICATIONS: , Preoperative cardiac evaluation in the patient with chest pain in the setting of left hip fracture.,HISTORY OF PRESENT ILLNESS:,  The patient is a 78-year-old white female with no prior cardiac history.  She sustained a mechanical fall with a subsequent left femoral neck fracture.  She was transferred to XYZ Hospital for definitive care.  In the emergency department of XYZ, the patient described six to seven seconds of sharp chest pain without radiation, without associated symptoms.  Electrocardiogram was obtained, which showed nonspecific ST-segment flattening in the high lateral leads I, aVL.  She also had a left axis deviation.  Serial troponins were obtained.  She has had four negative troponins since admission.  Due to age and chest pain history, a cardiology consultation was requested preoperatively.,At the time of my evaluation, the patient complained of left hip pain, but no chest pain, dyspnea, or symptomatic dysrhythmia.,PAST MEDICAL HISTORY:,1.  Mesothelioma.,2.  Recurrent urinary tract infections.,3.  Gastroesophageal reflux disease/gastritis.,4.  Osteopenia.,5.  Right sciatica.,6.  Hypothyroidism.,7.  Peripheral neuropathy.,8.  Fibromyalgia.,9.  Chart review also suggests she has atherosclerotic heart disease and pneumothorax.  The patient denies either of these.,PAST SURGICAL HISTORY:,1.  Tonsillectomy.,2.  Hysterectomy.,3.  Appendectomy.,4.  Thyroidectomy.,5.  Coccygectomy.,6.  Cystoscopies times several.,7.  Bladder neck resuspension.,8.  Multiple breast biopsies.,ALLERGIES: , NO KNOWN DRUG ALLERGIES.,MEDICATIONS:,  At the time of evaluation include, 1.  Cefazolin 1 g intravenous (IV).  2.  Morphine sulfate.  3.  Ondansetron p.r.n.,OUTPATIENT MEDICATIONS: , 1.  Robaxin.  2.  Detrol 4 mg q.h.s.  3.  Neurontin 300 mg p.o. t.i.d.  4.  Armour Thyroid 90 mg p.o. daily.  5.  Temazepam, dose unknown p.r.n.  6.  Chloral hydrate, dose unknown p.r.n.,FAMILY HISTORY: , Mother had myocardial infarction in her 40s, died of heart disease in her 60s, specifics not known.  She knows nothing of her father's history.  She has no siblings.  There is no other history of premature atherosclerotic heart disease in the family.,SOCIAL HISTORY: , The patient is married, lives with her husband.  She is a lifetime nonsmoker, nondrinker.  She has not been getting regular exercise for approximately two years due to chronic sciatic pain.,REVIEW OF SYSTEMS: ,GENERAL:  The patient is able to walk one block or less prior to the onset of significant leg pain.  She ever denies any cardiac symptoms with this degree of exertion.  She denies any dyspnea on exertion or chest pain with activities of daily living.  She does sleep on two to three pillows, but denies orthopnea or paroxysmal nocturnal dyspnea.  She does have chronic lower extremity edema.  Her husband states that she has had prior chest pain in the past, but this has always been attributed to gastritis.  She denies any palpitations or tachycardia.  She has remote history of presyncope, no true syncope.,HEMATOLOGIC:  Negative for bleeding diathesis or coagulopathy.,ONCOLOGIC:  Remarkable for past medical history.,PULMONARY:  Remarkable for childhood pneumonia times several.  No recurrent pneumonias, bronchitis, reactive airway disease as an adult.,GASTROINTESTINAL:  Remarkable for past medical history.,GENITOURINARY:  Remarkable for past medical history.,MUSCULOSKELETAL:  Remarkable for past medical history.,CENTRAL NERVOUS SYSTEM:  Negative for tic, tremor, transient ischemic attack (TIA), seizure, or stroke.,PSYCHIATRIC:  Remarkable for history of depression as an adolescent, she was hospitalized at State Mental Institution as a young woman.  No recurrence.,PHYSICAL EXAMINATION:,GENERAL:  This is a well-nourished, well-groomed elderly white female who is appropriate and articulate at the time of evaluation.,VITAL SIGNS:  She has had a low-grade temperature of 100.4 degrees Fahrenheit on 11/20/2006, currently 99.6.  Pulse ranges from 123 to 86 beats per minute.  Blood pressure ranges from 124/65 to 152/67 mmHg.  Oxygen saturation on 2 L nasal cannula was 94%.,HEENT:  Exam is benign.  Normocephalic and atraumatic.  Extraocular motions are intact.  Sclerae anicteric.  Conjunctivae noninjected.  She does have bilateral arcus senilis.  Oral mucosa is pink and moist.nan