Cardiovascular / Pulmonary
Sample Name: Cardiac Consultation - 2
Description: To evaluate exercise-induced chest pain, palpitations, dizzy spells, shortness of breath, and abnormal EKG.
(Medical Transcription Sample Report)
CHIEF REASON FOR CONSULTATION: Evaluate exercise-induced chest pain, palpitations, dizzy spells, shortness of breath, and abnormal EKG.
HISTORY OF PRESENT ILLNESS: This 72-year-old female had a spell of palpitations that lasted for about five to ten minutes. During this time, patient felt extremely short of breath and dizzy. Palpitations lasted for about five to ten minutes without any recurrence. Patient also gives history of having tightness in the chest after she walks briskly up to a block. Chest tightness starts in the retrosternal area with radiation across the chest. Chest tightness does not radiate to the root of the neck or to the shoulder, lasts anywhere from five to ten minutes, and is relieved with rest. Patient gives history of having hypertension for the last two months. Patient denies having diabetes mellitus, history suggestive of previous myocardial infarction, or cerebrovascular accident.
1. Astelin nasal spray.
2. Evista 60 mg daily.
3. Lopressor 25 mg daily.
4. Patient was given a sample of Diovan 80 mg daily for the control of hypertension from my office.
FAMILY HISTORY: The patient is married, has six children who are doing fine. Father died of a stroke many years ago. Mother had arthritis.
SOCIAL HISTORY: The patient does not smoke or take any drinks.
ALLERGIES: THE PATIENT IS NOT ALLERGIC TO ANY MEDICATIONS.
REVIEW OF SYSTEMS: Otherwise negative.
GENERAL: Well-built, well-nourished white female in no acute distress.
VITAL SIGNS: Blood pressure is 160/80. Respirations 18 per minute. Heart rate 70 beats per minute. Patient weighs 133 pounds, height 64 inches. BMI is 22.
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 a II/VI systolic murmur best heard at the apex. There is no diastolic murmur or gallop heard.
ABDOMEN: Soft. There is no hepatosplenomegaly or ascites. No bruit heard over the aorta or renal vessels.
EXTREMITIES: No pedal edema. Femoral arterial pulsations are 3+, popliteal 2+. Dorsalis pedis and posterior tibialis are 1+ on both sides.
EKG from Dr. Xyz's office shows normal sinus rhythm, ST and T wave changes. Lipid profile, random blood sugar, BUN, creatinine, CBC, and LFTs are normal.
1. Exercise-induced chest pain.
2. Palpitations with dizziness.
3. Abnormal EKG.
5. Heart murmur.
1. Adenosine Myoview SPECT, 24-hour Holter monitor, echocardiogram.
2. Carotid ultrasound.
3. Micro-T wave alternans test.
4. Diovan 80 mg has been given to the patient from our sample closet for the control of hypertension.
5. Patient will be seen again in my office in two weeks.
Keywords: cardiovascular / pulmonary, chest pain, 3. micro-t wave, adenosine myoview spect, carotid ultrasound, chest tightness, holter monitor, abnormal ekg, alternans test, consultation, dizzy spells, palpitations, shortness of breath, myocardial, heart, carotid, murmur, ekg, hypertension, chest,