Sample Name: Gen Med Consult - 4
Description: Consultation for jaw pain.
(Medical Transcription Sample Report)
CHIEF COMPLAINT: Jaw pain this morning.
BRIEF HISTORY OF PRESENT ILLNESS: This is a very nice 53-year-old white male with no previous history of heart disease, was admitted to rule out MI and coronary artery disease. The patient has history of hypercholesterolemia, presently on Lipitor 20 mg a day and hyperthyroidism, on Synthroid 0.088 mg per day. Also, history of chronic diverticulitis with recent bouts. The patient has been doing well, seen in my office at the end of December for complete physical examination. I had ordered a stress test for him, then delayed due to a family illness. However, denies any chest pain or chest tightness with exertion. The patient was doing well. He was watching television yesterday afternoon or p.m. and fell asleep holding his head in his left hand. He awoke and noticed pain in the jaw and neck area, on both sides, but no shortness of breath, diaphoresis, nausea, or chest pain. He is able to go to sleep, woke up this morning with same discomfort, decided to call our office, talked to our triage nurse, who instructed to come to the emergency room for possibility of just having a cardiac event. The patient's pain resolved. He was given nitroglycerin in the emergency room drawing his blood pressure 67/32. Blood pressure quickly came back to normal with the patient's reverse Trendelenburg.
FAMILY HISTORY: Strongly positive for heart disease in his father. He had a bypass at age 60. Both parents are alive. Both have dementia. His father has history of coronary artery disease and multiple vascular strokes. He is in his 80s. His mother is 80, also with dementia. The patient does not smoke or drink.
PAST MEDICAL HISTORY: Remarkable for tonsillectomies.
MEDICATIONS: Synthroid and Lipitor.
REVIEW OF SYSTEMS: Noncontributory.
VITAL SIGNS: The patient's blood pressure is 113/74, pulse rate is 72, respiratory rate is 18. He is afebrile.
GENERAL: He is well-developed, well-nourished white male, in no acute distress.
HEENT: Pupils equal, round, and reactive to light and accommodation. Extraocular movements were intact. Throat was clear.
NECK: Supple. There is no organomegaly or thyromegaly. Carotids are +2 without bruits.
CHEST: Lungs are clear to auscultation and percussion.
ABDOMEN: Soft. There is no hepatosplenomegaly. Bowel sounds are active. No tenderness.
EXTREMITIES: No cyanosis, clubbing, or edema. Peripheral pulses 2+.
NEUROLOGICAL: Intact. Motor exam is 5/5.
LABORATORY STUDIES: EKG is within normal limits, good sinus rhythm. His axis is somewhat leftward. CBC and BMP were normal and cardiac enzymes were negative x1.
1. Jaw pain, sounds musculoskeletal. We will rule out angina equivalent.
PLAN: Lipitor and thyroid have been ordered. His chest pain unit protocol for the stress thallium that will be done in the morning. If test is negative, we will discharge home. If positive, we will consult Cardiology. The patient requests Dr. ABC.
Keywords: general medicine, chief complaint, brief history of present illness, jaw pain, physical examination, neck area, sinus rhythm, within normal limits, coronary artery disease, blood pressure, heart, pressure, jaw, disease, chest,