Patient Name: Murray R. Abbell
Patient ID: 001987 DOB: 01/15/2014 AGE: 87 SEX: M
Consultant: Dr. J.K. McLain, Cardiology
Requesting Physician: Martha C. Eden, MD, Geriatrics
Date of Consult: 17 September
Reason for Consult: Emphysema and congestive heart failure.
HISTORY: This 87 year old Caucasian male patient, has been diagnosed as having emphysema and congestive heart failure. He is referred for cardiac evaluation and 2-D echo. In January of this year, he had an exercise test, which the family understands was negative. He has no history of myocardial infraction. His only other cardiac testing has been exercise testing. He has never had a heart cath. He had atrial fibrillation, diagnosed many years ago, and is still followed with Coumadin. He denies chest pain. He has significant dyspnea, uses O2.
MEDICATIONS: Niacin, warfarin, diltiazem, Lanoxin, Singulair, potassium, Lasix, Atrovent, and Pulmicort.
RISK FACTORS: The patient quit smoking at 68, he does not know about hypertension. He denies diabetes. He does not know if he has an elevated cholesterol level.
PAST MEDICAL/SURGICAL HISTORY: Allergies, penicillin, from which he goes into anaphylactic shock.
OPERATIONS: Traumatic left great toe amputation.
CHRONIC ILLNESSES: PAD and COPD.
REVIEW OF SYSTEMS: This is negative, except as outlined above.
PERSONAL/SOCIAL HISTORY: The patient is a widower who lives alone. He is a heavy drinker and smoker who recently quit. He is retired military and is brought here today by his daughter.
PHYSICAL EXAM: BP, 146 over 70. P-60 and regular. In general, this is the most pleasant Caucasian male patient who appears to be in no acute distress. HEENT, one eye not visualized. He is deaf and wears bilateral hearing aids. The main jugular vein pressure is normal. Carotids are three plus bilaterally without bruits. Chest symmetric. Lungs are clear to osculation and procussion