Sample Type / Medical Specialty: Consult - History and Phy.
Sample Name: Pericardial Effusion
Description: The patient is an 84-year-old female presented to emergency room with shortness of breath, fatigue, and tiredness. Low-grade fever was noted last few weeks. The patient also has chest pain described as dull aching type in precordial region. No relation to exertion or activity. No aggravating or relieving factors.
(Medical Transcription Sample Report)
REASON FOR CONSULTATION: Pericardial effusion.
HISTORY OF PRESENT ILLNESS: The patient is an 84-year-old female presented to emergency room with shortness of breath, fatigue, and tiredness. Low-grade fever was noted last few weeks. The patient also has chest pain described as dull aching type in precordial region. No relation to exertion or activity. No aggravating or relieving factors. A CT of the chest was done, which shows pericardial effusion. This consultation is for the same. The patient denies any lightheadedness or dizziness. No presyncope or syncope. Activity is fairly stable.
CORONARY RISK FACTORS: History of borderline hypertension. No history of diabetes mellitus. Nonsmoker. Cholesterol status is within normal limits. No history of established coronary artery disease. Family history noncontributory.
FAMILY HISTORY: Nonsignificant.
PAST SURGICAL HISTORY: Hysterectomy and bladder surgery.
PERSONAL HISTORY: She is a nonsmoker. She does not consume alcohol. No history of recreational drug use.
PAST MEDICAL HISTORY:
2. Borderline hypertension.
REVIEW OF SYSTEMS
CONSTITUTIONAL: Weakness, fatigue, and tiredness.
HEENT: No history of cataract, blurring of vision, or glaucoma.
CARDIOVASCULAR: Chest pain. No congestive heart failure. No arrhythmia.
RESPIRATORY: No history of pneumonia in the past, valley fever.
GASTROINTESTINAL: Epigastric discomfort. No hematemesis or melena.
UROLOGICAL: Frequency. No urgency. No hematuria.
MUSCULOSKELETAL: Arthritis and muscle weakness.
VITAL SIGNS: Pulse of 86, blood pressure 93/54, afebrile, respiratory rate 16 per minute.
HEENT: Atraumatic and normocephalic.
NECK: Supple. Neck veins flat. No significant carotid bruit.
LUNGS: Air entry bilaterally fair.
HEART: PMI displaced. S1 and S2 regular.
ABDOMEN: Soft and nontender.
EXTREMITIES: No edema. Pulses palpable. No clubbing or cyanosis.
CNS: Grossly intact.
LABORATORY DATA: White count of 20 and H&H 13 and 39. BUN and creatinine within normal limits. Cardiac enzyme profile negative.
RADIOGRAPHIC STUDIES: CT of the chest preliminary report, pericardial effusion. Echocardiogram shows pericardial effusion, which appears to be chronic. There is no evidence of hemodynamic compromise.
1. The patient is an 84-year-old female admitted with chest pain and shortness of breath, possibly secondary to pulmonary disorder. She has elevated white count, possible infection.
2. Pericardial effusion without any hemodynamic compromise, could be chronic.
3. Cardiac risk factors minimum, except for age and borderline hypertension.
1. Antibiotic treatment and see how she fares.
2. Based on response, we will consider cardiac workup in terms of stress test once she is stable.
3. As for the pericardial effusion, continue with observation.
Keywords: consult - history and phy., shortness of breath, fatigue, tiredness, exertion, lightheadedness, dizziness, elevated white count, fatigue and tiredness, white count, hemodynamic compromise, borderline hypertension, hemodynamic, hypertension, cardiac, breath, effusion, chest, pericardial,