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INDICATIONS: Preoperative cardiac evaluation in the patient with chest pain in the setting of left hip fracture.

HISTORY OF PRESENT ILLNESS: The patient is a 78-year-old white female with no prior cardiac history. She sustained a mechanical fall with a subsequent left femoral neck fracture. She was transferred to XYZ Hospital for definitive care. In the emergency department of XYZ, the patient described six to seven seconds of sharp chest pain without radiation, without associated symptoms. Electrocardiogram was obtained, which showed nonspecific ST-segment flattening in the high lateral leads I, aVL. She also had a left axis deviation. Serial troponins were obtained. She has had four negative troponins since admission. Due to age and chest pain history, a cardiology consultation was requested preoperatively.

At the time of my evaluation, the patient complained of left hip pain, but no chest pain, dyspnea, or symptomatic dysrhythmia.

PAST MEDICAL HISTORY:
1. Mesothelioma.
2. Recurrent urinary tract infections.
3. Gastroesophageal reflux disease/gastritis.
4. Osteopenia.
5. Right sciatica.
6. Hypothyroidism.
7. Peripheral neuropathy.
8. Fibromyalgia.
9. Chart review also suggests she has atherosclerotic heart disease and pneumothorax. The patient denies either of these.

PAST SURGICAL HISTORY:
1. Tonsillectomy.
2. Hysterectomy.
3. Appendectomy.
4. Thyroidectomy.
5. Coccygectomy.
6. Cystoscopies times several.
7. Bladder neck resuspension.
8. Multiple breast biopsies.

ALLERGIES: NO KNOWN DRUG ALLERGIES.

MEDICATIONS: At the time of evaluation include, 1. Cefazolin 1 g intravenous (IV). 2. Morphine sulfate. 3. Ondansetron p.r.n.

OUTPATIENT MEDICATIONS: 1. Robaxin. 2. Detrol 4 mg q.h.s. 3. Neurontin 300 mg p.o. t.i.d. 4. Armour Thyroid 90 mg p.o. daily. 5. Temazepam, dose unknown p.r.n. 6. Chloral hydrate, dose unknown p.r.n.

FAMILY HISTORY: Mother had myocardial infarction in her 40s, died of heart disease in her 60s, specifics not known. She knows nothing of her father's history. She has no siblings. There is no other history of premature atherosclerotic heart disease in the family.

SOCIAL HISTORY: The patient is married, lives with her husband. She is a lifetime nonsmoker, nondrinker. She has not been getting regular exercise for approximately two years due to chronic sciatic pain.

REVIEW OF SYSTEMS:
GENERAL: The patient is able to walk one block or less prior to the onset of significant leg pain. She ever denies any cardiac symptoms with this degree of exertion. She denies any dyspnea on exertion or chest pain with activities of daily living. She does sleep on two to three pillows, but denies orthopnea or paroxysmal nocturnal dyspnea. She does have chronic lower extremity edema. Her husband states that she has had prior chest pain in the past, but this has always been attributed to gastritis. She denies any palpitations or tachycardia. She has remote history of presyncope, no true syncope.
HEMATOLOGIC: Negative for bleeding diathesis or coagulopathy.
ONCOLOGIC: Remarkable for past medical history.
PULMONARY: Remarkable for childhood pneumonia times several. No recurrent pneumonias, bronchitis, reactive airway disease as an adult.
GASTROINTESTINAL: Remarkable for past medical history.
GENITOURINARY: Remarkable for past medical history.
MUSCULOSKELETAL: Remarkable for past medical history.
CENTRAL NERVOUS SYSTEM: Negative for tic, tremor, transient ischemic attack (TIA), seizure, or stroke.
PSYCHIATRIC: Remarkable for history of depression as an adolescent, she was hospitalized at State Mental Institution as a young woman. No recurrence.

PHYSICAL EXAMINATION:
GENERAL: This is a well-nourished, well-groomed elderly white female who is appropriate and articulate at the time of evaluation.
VITAL SIGNS: She has had a low-grade temperature of 100.4 degrees Fahrenheit on 11/20/2006, currently 99.6. Pulse ranges from 123 to 86 beats per minute. Blood pressure ranges from 124/65 to 152/67 mmHg. Oxygen saturation on 2 L nasal cannula was 94%.
HEENT: Exam is benign. Normocephalic and atraumatic. Extraocular motions are intact. Sclerae anicteric. Conjunctivae noninjected. She does have bilateral arcus senilis. Oral mucosa is pink and moist.
NECK: Jugular venous pulsations are normal. Carotid upstrokes are palpable bilaterally. There is no audible bruit. There is no lymphadenopathy or thyromegaly at the base of the neck. There is a well-healed scar at the base of the neck. Cardiothoracic contour is normal.
LUNGS: Limited to anterior auscultation only, which was clear.
CARDIAC: Regular rhythm and rate. S1 and S2 with no significant murmur, rub, or gallop appreciated. The point of maximal impulse is normal. There is no right ventricular heave.
ABDOMEN: Soft with active bowel sounds. No organomegaly. No audible bruit. Nontender.
EXTREMITIES: Femoral pulses were deferred. Lower extremities revealed trace to 1+edema at the level of ankles bilaterally.

DIAGNOSTIC DATA: EKG: Electrocardiogram on 11/20/2006 at 1539 showed sinus rhythm with left axis deviation, borderline first-degree atrioventricular (AV) block, sinus arrhythmia. Nonspecific ST-segment flattening seen predominantly in aVL, but to a lesser extent in lead I. Early R-wave progression also noted. No evidence for resting ischemia or prior infarction. Repeat electrocardiogram on 11/21/2006 at 0037 essentially unchanged with regard to ST segments except there is perhaps slightly more flattening in lead I. P-wave morphology is slightly different than that noted on prior tracing consistent with ectopic atrial rhythm. Repeat electrocardiogram on 11/21/2006 at 1713 shows persistence of ST segment flattening in lead I, aVL. Persistence of early R-wave progression and left axis deviation. Rhythm does appear to be sinus on current tracing.

LABORATORY DATA: White blood cell count 4.7 on admission, hematocrit currently 33.2 with platelet count of 243 on admission. INR 1.0 with PTT of 20. Sodium 144 with potassium 3.6, chloride 107, CO2 25, BUN 10 with creatinine of 1.1. Albumin depressed at 3.3. AST and ALT normal at 19 and 24 respectively, lipase normal at 45. Troponins are negative x4 over the course of 14 hours. Urinalysis is suggestive of urinary tract infection (UTI) with no blood, positive nitrates, positive leuk esterase, 5 to 10 white blood cells, and many bacteria with no epithelial cells.

IMPRESSION: Elderly white female status post traumatic left hip fracture with atypical chest pain and baseline ST-segment abnormalities nondiagnostic.

RECOMMENDATIONS:
1. Cardiac clearance: The patient with cardiac risk factors including age and family. Not smoking, hypertensive, dyslipidemic. Does have a sedentary lifestyle, but it is not morbidly obese. Given the atypical nature of her chest pain and the nondiagnostic EKG changes, I feel it is safe to proceed with orthopedic procedure without further cardiac evaluation. We would, however, treat with preoperative beta-blockers.
2. We will follow the patient perioperatively with electrocardiogram and troponin.
3. We would recommend treatment for presumed urinary tract infection.

FOLLOWUP: The patient will be followed in-house by members of Cardiology Associates and recommendations made as clinically appropriate.

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