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30m Consult Summary
History of Present Illness
The patient is a 53 year old male with a past medical history of atrial fibrillation, diabetes, hypertension. The patient presented with shortness of breath and chest tightness, also associated with dizziness. The symptoms occur during strenuous activity like walking up stairs or going on a hike, and with lifting heavy objects.
Physical Exam
General: Well appearing, in no acute distress
Cardiovascular: Regular rate and rhythm with no murmurs, rubs, or gallops.
Pulmonary: Clear to auscultation bilaterally, no wheezes, rales, or rhonchi.
Cardiovascular: Regular rate and rhythm with no murmurs, rubs, or gallops.
Pulmonary: Clear to auscultation bilaterally, no wheezes, rales, or rhonchi.
History of Present Illness
The patient is a 53 year old male with a past medical history of atrial fibrillation, diabetes, hypertension. The patient presented with shortness of breath and chest tightness, also associated with dizziness. The symptoms occur during strenuous activity like walking up stairs or going on a hike, and with lifting heavy objects.
Physical Exam
General: Well appearing, in no acute distress
Cardiovascular: Regular rate and rhythm with no murmurs, rubs, or gallops.
Pulmonary: Clear to auscultation bilaterally, no wheezes, rales, or rhonchi.
Cardiovascular: Regular rate and rhythm with no murmurs, rubs, or gallops.
Pulmonary: Clear to auscultation bilaterally, no wheezes, rales, or rhonchi.
Assessment & Plan
shortness of breath
R06.09
Plan to perform EKG and echocardiogram this afternoon to assess heart function.
hypertension
I15.2
Patient will start taking lisinopril 10mg a day to protect heart and lower blood pressure.
diabetes
HCC 18
Last hemoglobin A1c elevated at 8. Patient has not been able to afford metformin. Social worker consulted to help with medication supplies for metformin 500mg twice daily.
Patient Instructions
For Your shortness of breath
We will perform an EKG and echocardiogram this afternoon to assess heart function.
For Your hypertension
Start taking lisinopril 10mg a day to protect heart and lower blood pressure.
For Your diabetes
Continue taking metformin 500mg twice daily. A social worker will contact you to help you afford your medication.
diabetes
hypertension
shortness of breath
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