Sample Cardiology Transcription
Report
HISTORY:
The patient is a 48-year-old female with a long history
of atypical chest pain and palpitations. As a part of
her evaluation in the past, she has undergone an
echocardiogram, which did show mitral valve prolapse.
She describes her episodes of chest pain as burning and
tingling in nature. They are not associated with
exertion. They typically will last for five minutes but
are not associated with shortness of breath . These
occur once a week. The patient also notes a history of
palpitations, which are improved on her Tenormin and her
verapamil. She denies diaphoresis or lightheadedness and
any history of MI.
PAST MEDICAL HISTORY:
Mitral valve prolapse, atypical chest pain and
palpitations.
PAST SURGICAL HISTORY:
Hysterectomy, bladder suspension and appendectomy.
CURRENT MEDICATIONS:
Atenolol 50 mg a day, verapamil 120 mg a day, one baby
aspirin a day and Celexa 40 mg a day.
SOCIAL HISTORY:
Positive for tobacco abuse.
FAMILY HISTORY:
Positive for coronary artery disease.
REVIEW OF SYSTEMS:
She denies fevers, chest pain, night sweats, strokes,
cough or diabetes mellitus. Otherwise, ten-point review
of systems is negative.
PHYSICAL EXAMINATION:
She is in no acute distress. Her neck veins are not
distended. Respiratory exam is clear to auscultation.
Cardiac exam reveals a normal rate and rhythm. Normal S1
and S2. No murmur, rubs, clicks are clearly auscultated.
Abdomen is soft and nontender to palpation without
organomegaly. Extremities reveal no clubbing, cyanosis
or edema. GU exam reveals no costovertebral angle
tenderness. Her neurological examination is nonfocal.
ELECTROCARDIOGRAM:
Sinus rhythm without significant ST segment
abnormalities.
IMPRESSION:
1. Chest pain with atypical features: As it is not
associated with exertion and has radiation over to her
body. No clear explanation has been found for this.
Whether this represents any arrhythmia, a cardiac or
non-cardiac problem is unclear.
2. Palpitations: The patient had an evaluation for this
in the past with limited Holter, which was not helpful.
3. Mitral valve prolapse: No clear evidence of this has
been made, although it has been documented under
previous echo. No murmur was noted on the examination.
RECOMMENDATIONS:
The patient presents with symptoms of palpitations,
atypical chest pain and preserved exercise tolerance. No
good explanation of her chest pain has been found. I
have recommended getting an event recorder to try to
calibrate her symptoms to arrhythmia or ST segment
changes. In addition, I have checked a basic metabolic
factor such as a C-reactive protein, lipid, CBC, TSH,
UA, and BMP. I plan to see her in follow-up after six
weeks. If she has no clear explanation for this,
depending on what her event recorder shows possible
further evaluation may include consideration of an
empiric trial for reflux, evaluation of her gallbladder
in view of negative possible cardiac catheterizations to
rule out coronary artery disease certainty.
For more samples of our medical
transcription service within dermatology, neurology,
psychiatry, dentistry, radiology transcription and other
specialties, please contact us.
|
