Clinical note · #36
Consultation
Patient: Robert Hayes
Age: 71
Place of Service: Office – Outpatient
Patient Status: New Patient
Insurance: Commercial PPO
Referring Provider: Dr. A. Patel (Internal Medicine)
Reason for Consultation: Urgent cardiovascular evaluation and management recommendations for exertional chest pain.
Chief Complaint: Chest pain with exertion.
History of Present Illness (HPI):
The patient is a 71-year-old male referred for cardiology consultation due to progressive exertional chest pain over the past three weeks. The pain is described as substernal pressure radiating to the left arm, occurring with minimal exertion and relieved by rest.
He reports associated shortness of breath and diaphoresis. He denies syncope or palpitations. An external stress test performed by the referring provider demonstrated significant ischemic changes. Given these high-risk features, urgent consultation was requested.
Review of Systems (ROS):
- Cardiovascular: Chest pain, exertional dyspnea
- Respiratory: Shortness of breath
- Neurologic: Denies syncope
- All other systems reviewed and negative
Past, Family, and Social History:
- PMH: Hypertension, hyperlipidemia
- PSH: None
- FH: Father died of myocardial infarction at age 65
- SH: Former smoker (30 pack-years)
Physical Examination:
- General: Appears uncomfortable
- Cardiovascular: Regular rhythm, no murmurs
- Lungs: Clear to auscultation
- Extremities: No edema
Assessment:
- Unstable angina / suspected acute coronary syndrome
Plan:
- Immediate referral for cardiac catheterization
- Initiate aspirin and beta-blocker therapy
- Consultation report sent to referring provider