Upload sample_docs/consult_note_003.txt

sample_docs/consult_note_003.txt

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+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