Sample Type / Medical Specialty: Consult - History and Phy.
Sample Name: Gen Med Consult - 54
Description: The patient is a 35-year-old lady who was admitted with chief complaints of chest pain, left-sided with severe chest tightness after having an emotional argument with her boyfriend. The patient has a long history of psychological disorders.
(Medical Transcription Sample Report)
HISTORY OF PRESENT ILLNESS: The patient is a 35-year-old lady who was admitted with chief complaints of chest pain, left-sided with severe chest tightness after having an emotional argument with her boyfriend. The patient has a long history of psychological disorders. As per the patient, she also has a history of supraventricular tachycardia and coronary artery disease, for which the patient has had workup done in ABC Medical Center. The patient was evaluated in the emergency room. The initial cardiac workup was negative. The patient was admitted to telemetry unit for further evaluation. In the emergency room, the patient was also noted to have a strongly positive drug screen including methadone and morphine. The patient's EKG in the emergency room was normal and the patient had some relief from her chest pain after she got some nitroglycerin.
PAST MEDICAL HISTORY: As mentioned above is significant for history of seizure disorder, migraine headaches, coronary artery disease, CHF, apparently coronary stenting done, mitral valve prolapse, supraventricular tachycardia, pacemaker placement, colon cancer, and breast cancer. None of the details of these are available.
PAST SURGICAL HISTORY: Significant for history of lumpectomy on the left breast, breast augmentation surgery, cholecystectomy, cardiac ablation x3, left knee surgery as well as removal of half the pancreas.
CURRENT MEDICATIONS AT HOME: Included Dilantin 400 mg daily, Klonopin 2 mg 3 times a day, Elavil 300 mg at night, nitroglycerin sublingual p.r.n., Thorazine 300 mg 3 times a day, Neurontin 800 mg 4 times a day, and Phenergan 25 mg as tolerated.
OB HISTORY: Her last menstrual period was 6/3/2009. The patient is admitting to having a recent abortion done. She is not too sure whether the abortion was completed or not, has not had a followup with her OB/GYN.
SOCIAL HISTORY: She lives with her boyfriend. The patient has history of tobacco abuse as well as multiple illicit drug abuse.
REVIEW OF SYSTEMS: As mentioned above.
GENERAL: She is alert, awake, and oriented.
VITAL SIGNS: Her blood pressure is about 132/72, heart rate of about 87 per minute, respiratory rate of 16.
HEENT: Shows head is atraumatic. Pupils are round and reactive to light. Extraocular muscles are intact. No oropharyngeal lesions noted.
LUNGS: Clear to auscultation bilaterally.
CARDIAC: Reveals regular rate and rhythm.
ABDOMEN: Soft, nontender, nondistended. Bowel sounds are normally present.
LOWER EXTREMITIES: Shows no edema. Distal pulses are 2+.
NEUROLOGICAL: Grossly nonfocal.
LABORATORY DATA: The database that is available at this point of time, WBC count is normal, hemoglobin and hematocrit are normal. Sodium, potassium, chloride, glucose, bicarbonate, BUN and creatinine, and liver function tests are normal. The patient's 3 sets of cardiac enzymes including troponin-I, CPK-MB, and myoglobulin have been normal. EKG is normal, sinus rhythm without any acute ST-T wave changes. As mentioned before, the patient's toxicology screen was positive for morphine, methadone, and marijuana. The patient also had a head CT done in the emergency room, which was fairly unremarkable. The patient's beta-hCG level was marginally elevated at about 48.
ASSESSMENT AND EVALUATION:
2. Possible early pregnancy. The patient's case was discussed with OB/GYN on-call over the phone. Some of the medications have to be held secondary to potential danger. The patient will follow up on an outpatient basis with her primary OB/GYN as well as PCP for the workup of her pregnancy as well as continuation of the pregnancy and prenatal visits.
3. Migraine headaches for which the patient has been using her routine medications and the headaches seem to be under control. Again, this is an outpatient diagnosis. The patient will follow up with her PCP for control of migraine headache.
Overall prognosis is too soon to predict.
The plan is to discharge the patient home secondary to no evidence of acute coronary syndrome.
Keywords: consult - history and phy., psychosomatic, coronary artery disease, chest tightness, emotional argument, psychological disorders, supraventricular tachycardia, headaches,