Sample Type / Medical Specialty: Consult - History and Phy.
Sample Name: Cardiac Consultation - 1
To evaluate recurrent episodes of uncomfortable feeling in arm at rest, as well as during exertion.
(Medical Transcription Sample Report)
CHIEF REASON FOR CONSULTATION:
Evaluate recurrent episodes of uncomfortable feeling in the left upper arm at rest, as well as during exertion for the last one month.HISTORY OF PRESENT ILLNESS:
This 57-year-old black female complains of having pain and discomfort in the left upper arm, especially when she walks and after heavy meals. This lasts anywhere from a few hours and is not associated with shortness of breath, palpitations, dizziness, or syncope. Patient does not get any chest pain or choking in the neck or pain in the back. Patient denies history of hypertension, diabetes mellitus, enlarged heart, heart murmur, history suggestive of previous myocardial infarction, or acute rheumatic polyarthritis during childhood. Her exercise tolerance is one to two blocks for shortness of breath and easy fatigability.MEDICATIONS:
Patient does not take any specific medications.PAST HISTORY:
The patient underwent hysterectomy in 1986.FAMILY HISTORY:
The patient is married, has four children who are doing fine. Family history is positive for hypertension, congestive heart failure, obesity, cancer, and cerebrovascular accident.SOCIAL HISTORY:
The patient smokes one pack of cigarettes per day and takes drinks on social occasions. ALLERGIES:
THE PATIENT IS ALLERGIC TO CODEINE.REVIEW OF SYSTEMS:
Remarkable for heavy snoring, daytime sleepiness, and easy fatigability.PHYSICAL EXAMINATION:
GENERAL: Well-built, well-nourished black female in no acute distress.
VITAL SIGNS: Blood pressure is 120/80. Respirations 18 per minute. Heart rate 70 beats per minute. Patient weighs 226 pounds, height 68 inches. BMI is 34.
HEENT: Head normocephalic. Eyes, no evidence of anemia or jaundice. Oral hygiene is good.
NECK: Supple. No cervical lymphadenopathy. Carotid upstroke is good. No bruit heard over the carotid or subclavian arteries. Trachea in midline. Thyroid not enlarged. JVP flat at 45°.
CHEST: Chest is symmetrical on both sides, moves well with respirations. Vesicular breath sounds heard over the lung fields. No wheezing, crepitation, or pleural friction rub heard.
CARDIOVASCULAR SYSTEM: PMI felt in fifth left intercostal space within midclavicular line. First and second heart sounds are normal in character. There is no murmur, gallop, or pericardial friction rub heard.
ABDOMEN: Soft. There is no hepatosplenomegaly or ascites. No bruit heard over the aorta or renal vessels.
EXTREMITIES: No pedal edema or calf muscle tenderness. Proximal and distal arterial pulsations are well felt.
EKG shows normal sinus rhythm, negative T waves in leads 1, aVL, V4-V6.IMPRESSION:
1. Abnormal EKG showing diffuse anterior wall ischemia.
2. Discomfort left upper arm highly suggestive of angina pectoris.
4. Obstructive sleep apnea syndrome.PLAN:
1. Stress Myoview SPECT, echocardiogram.
2. Sleep apnea study.
3. Routine blood tests.
4. Patient will be seen again in my office in two weeks.
consult - history and phy., consultation, abnormal ekg, cardiac consultation, ekg, obstructive sleep apnea, stress myoview spect, angina pectoris, echocardiogram, intercostal space, midclavicular line, pain and discomfort, upper arm, apnea, chest, sleepiness, arm, heart,
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