Sample Type / Medical Specialty: Consult - History and Phy.
Sample Name: Consult - Abnormal EKG
Abnormal EKG and rapid heart rate. The patient came to the emergency room. Initially showed atrial fibrillation with rapid ventricular response. It appears that the patient has chronic atrial fibrillation. She denies any specific chest pain. Her main complaint is shortness of breath and symptoms as above.
(Medical Transcription Sample Report)
REASON FOR CONSULTATION:
Abnormal EKG and rapid heart rate.HISTORY OF PRESENT ILLNESS:
The patient is an 86-year-old female. From the last few days, she is not feeling well, fatigue, tiredness, weakness, nausea, no vomiting, no hematemesis or melena. The patient relates to have some low-grade fever. The patient came to the emergency room. Initially showed atrial fibrillation with rapid ventricular response. It appears that the patient has chronic atrial fibrillation. As per the medications, they are not very clear. Husband has gone out to brief her medications. She denies any specific chest pain. Her main complaint is shortness of breath and symptoms as above.CORONARY RISK FACTORS:
No hypertension or diabetes mellitus. Nonsmoker. Cholesterol status is normal. Questionable history of coronary artery disease. Family history noncontributory.FAMILY HISTORY:
Nonsignificant.PAST SURGICAL HISTORY:
Questionable coronary artery bypass surgery versus valve replacement.MEDICATIONS:
Unclear at this time, but she does take Coumadin.ALLERGIES:
She is married, nonsmoker. Does not consume alcohol. No history of recreational drug use.PAST MEDICAL HISTORY:
Symptoms as above, atrial fibrillation, history of open heart surgery, possible bypass surgery; however, after further query, husband relates that she may had just a valve surgery.REVIEW OF SYSTEMS
CONSTITUTIONAL: Weakness, fatigue, and tiredness.
HEENT: No history of cataract, history of blurry vision and hearing impairment.
CARDIOVASCULAR: Irregular heart rhythm with congestive heart failure, questionable coronary artery disease.
RESPIRATORY: Shortness of breath, questionable pneumonia. No valley fever.
GASTROINTESTINAL: No nausea, no vomiting, hematemesis or melena.
UROLOGICAL: No frequency or urgency.
MUSCULOSKELETAL: Arthritis, muscle weakness.
CNS: No TIA. No CVA. No seizure disorder.
PSYCHOLOGIC: Anxiety and depression.
ALLERGIES: Nonsignificant except as mentioned above for medications.PHYSICAL EXAMINATION
VITAL SIGNS: Pulse of 122, blood pressure 148/78, afebrile, and respiratory rate 18 per minute.
HEENT AND NECK: Neck is supple. Atraumatic and normocephalic. Neck veins are flat. No thyromegaly.
LUNGS: Air entry bilaterally fair. Decreased breath sounds especially in the right basilar areas. Few crackles.
HEART: Normal S1 and S2, irregular.
ABDOMEN: Soft and nontender.
EXTREMITIES: No edema. Pulse is palpable. No clubbing or cyanosis.
CNS: Grossly intact.
MUSCULOSKELETAL: Arthritic changes.
PSYCHOLOGICAL: None significant.DIAGNOSTIC DATA:
EKG, atrial fibrillation with rapid ventricular response, and nonspecific ST-T changes. INR of 4.5, H and H 10 and 30. BUN and creatinine are within normal limits. Chest x-ray confirmed right lower lobe patchy infiltrate, and trace of pneumonia.IMPRESSION:
1. The patient is an 86-year-old female who has questionable bypass surgery, questionable valve surgery with a rapid atrial heart rate, chronic atrial fibrillation with rapid ventricular response, exacerbated by most likely underlying pneumonia by chest x-ray findings.
2. Symptoms as above.RECOMMENDATIONS:
1. We will start her on a low dose of beta-blocker for rate control and antibiotic for pneumonia. Once, if she is stable, we will consider further cardiac workup.
2. We will also obtain an echocardiogram to assess valves such as whether she had a prior valve surgery versus coronary artery bypass surgery.
3. Discussed with the patient's husband regarding plan of care, fully understood, and consents for the same. All the questions answered in detail.
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