Consult - History and Phy.
Sample Name: Cardiac Consultation - 4
Description: Patient with right-sided chest pain, borderline elevated high blood pressure, history of hyperlipidemia, and obesity.
(Medical Transcription Sample Report)
REASON FOR CONSULTATION: Cardiac evaluation.
HISTORY: This is a 42-year old Caucasian male with no previous history of hypertension, diabetes mellitus, rheumatic fever, rheumatic heart disease, or gout. Patient used to take medicine for hyperlipidemia and then that was stopped. He used to live in Canada and he moved to Houston four months ago. He started complaining of right-sided upper chest pain, starts at the right neck and goes down to the right side. It lasts around 10-15 minutes at times. It is 5/10 in quality. It is not associated with shortness of breath, nausea, vomiting, or sweating. It is not also associated with food. He denies exertional chest pain, dyspnea on exertion, orthopnea, paroxysmal nocturnal dyspnea, or pedal edema. No palpitations, syncope or presyncope. He said he has been having little cough at night and he went to see an allergy doctor who prescribed several medications for him and told him that he has asthma. No fever, chills, cough, hemoptysis, hematemesis or hematochezia. His EKG shows normal sinus rhythm, normal EKG.
PAST MEDICAL HISTORY: Unremarkable, except for hyperlipidemia.
SOCIAL HISTORY: He said he quit smoking 20 years ago and does not drink alcohol.
FAMILY HISTORY: Positive for high blood pressure and heart disease. His father died in his 50s with an acute myocardial infarction.
ALLERGIES: No known allergies.
REVIEW OF SYSTEMS: As mentioned above
EXAMINATION: This is a 42-year old male awake, alert, and oriented x3 in no acute distress.
Wt: 238 BP: 144/82 HR: 69
HEENT: Normocephalic and atraumatic.
NECK: Supple, no jugular venous distension.
HEART: Regular rate and rhythm, S1 and S2, no murmurs, rubs, or gallops.
ABDOMEN: Soft, no organomegalies, bowel sounds positive.
EXTREMITIES: No clubbing, edema, or cyanosis.
1. Right-sided chest pain, rule out coronary artery disease, rule out C-spine radiculopathy, rule out gallbladder disease.
2. Borderline elevated high blood pressure.
3. History of hyperlipidemia.
PLAN: Will schedule patient for heart catheterization. Will see him after the above is completed.
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