sample_docs/consult_note_003.txt

CARDIOLOGY CONSULTATION NOTE
Date: 2026-06-01
Referring Provider: Dr. Angela Torres, NP — Riverside Family Medicine
Consultant: Dr. James Okafor, MD, FACC — Riverside Cardiology Associates

PATIENT: Maria L. (MRN: 00456)
DOB: 1978-03-14 | Age: 48 | Sex: Female

REASON FOR CONSULTATION:
Referred for evaluation of exertional chest tightness in a patient with known asthma.
Rule out cardiac etiology.

HISTORY OF PRESENT ILLNESS:
Ms. L. is a 48-year-old woman with moderate persistent asthma, allergic rhinitis, and GERD
presenting with a 3-week history of exertional chest tightness. She reports the tightness occurs
with moderate exertion (walking upstairs, brisk walking) and resolves within 5 minutes of rest.
She denies radiation to the arm or jaw, diaphoresis, or syncope. No palpitations.
Her primary care provider has recently stepped up her asthma therapy (Prednisone 40mg × 5 days,
added per the recent intake note dated 2026-06-01). She is a non-smoker with no family history
of early coronary artery disease.

CURRENT MEDICATIONS (from PCP intake note 2026-06-01):
1. Fluticasone/Salmeterol (Advair Diskus) 250/50 mcg — 1 puff inhaled BID
2. Albuterol HFA 90mcg — 2 puffs PRN rescue
3. Montelukast 10mg — nightly
4. Omeprazole 20mg — once daily
5. Prednisone 40mg — daily × 5 days (course ending ~2026-06-06)

IMPORTANT DRUG NOTE:
Albuterol (beta-2 agonist) may cause cardiac palpitations and mild tachycardia, which can mimic
cardiac symptoms. Montelukast carries a rare FDA black-box warning for neuropsychiatric effects
but no direct cardiac interaction in this patient's current regimen.
Non-selective beta-blockers are CONTRAINDICATED in this patient given active asthma.

ALLERGIES (confirmed from PCP record):
- Aspirin — bronchospasm (absolutely contraindicated; rules out standard ACS antiplatelet therapy)
- Sulfonamides — rash

PHYSICAL EXAMINATION:
Vitals: BP 126/80, HR 88 bpm (regular), RR 16/min, SpO2 97% RA
Cardiovascular: Regular rate and rhythm. No murmurs, rubs, or gallops. JVP not elevated.
Peripheral pulses 2+ bilaterally. No peripheral edema.

INVESTIGATIONS:
- 12-lead ECG: Normal sinus rhythm. No ST changes. Normal intervals.
- Resting echocardiogram: Normal LV systolic function (EF 62%). No wall motion abnormalities.
  Mild mitral valve regurgitation (trace — clinically insignificant).
- BNP: 42 pg/mL (normal).
- Troponin I: <0.01 ng/mL (negative × 2, 3 hours apart).

IMPRESSION:
1. Exertional chest tightness — most likely exertional asthma / exercise-induced bronchoconstriction
   rather than ACS or stable angina based on normal cardiac workup.
2. Trace mitral regurgitation — incidental finding, no intervention required, annual echo surveillance.
3. NSAID/Aspirin contraindicated (aspirin allergy with bronchospasm) — important for future
   cardiovascular risk management.

PLAN:
1. Recommend exercise stress test (treadmill) to definitively exclude exertional ischemia.
   Schedule within 2 weeks.
2. If stress test negative: reassure, optimize asthma management.
3. If aspirin-indicated in future (e.g. ACS): use Clopidogrel 75mg as alternative antiplatelet.
4. No cardiac medications added at this time.
5. Continue current asthma regimen per PCP.
6. Annual echo for MR surveillance.

FOLLOW-UP: Cardiology clinic in 3 weeks (post stress test) — June 22, 2026.
Return to ED if chest pain at rest, diaphoresis, or sustained palpitations.

Electronically signed: Dr. James Okafor, MD, FACC