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CARDIOLOGY - History & Physical

HISTORY:
The patient is a 54-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 followup 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.

CARDIOLOGY DISCHARGE SUMMARY

DISCHARGE DIAGNOSES:
1. Chest pain, undetermined etiology. No evidence of acute myocardial infarction. I doubt angina pectoris.
2. Shortness of breath secondary to probable obstructive pulmonary disease. Pulmonary function studies pending.
3. Chest discomfort, probably on the basis of obstructive pulmonary disease.

PROCEDURES PERFORMED: Treadmill exercise electrocardiogram prior to the discharge, which was nondiagnostic of myocardial ischemia and limited by shortness of breath and fatigue.

IDENTIFICATION AND HISTORY: This patient is a 65-year-old Portuguese female. She is currently admitted to the hospital with chest pain. She has no previous history of documented arteriosclerotic heart disease. She is admitted to rule out myocardial infarction versus unstable angina pectoris.

Her risk factors include smoking, hypertension, and borderline diabetes.

PHYSICAL EXAMINATION: Physical exam at the time of admission revealed her lungs to have decreased breath sounds but no frank wheezes or rales. She was not dyspneic or tachypneic. HEART: Heart sounds were regular. S1 and S2 were normal. No significant murmur, gallop, or rub. ABDOMEN: Abdominal exam was benign.

HOSPITAL COURSE: She had no arrhythmias. She had no recurrence of her chest pain.

DISCHARGE PLANS: Discharge plans include the following:
1. Pulmonary function studies including pre- and post-bronchial dilator spirometry to establish a diagnosis of her obstructive pulmonary disease, which is suspected clinically.
2. Cardizem 60 mg 1 q.i.d., mainly because of her hypertension.
3. Nitroglycerin sublingual grains 1/150 p.r.n. chest pain.
4. Premarin 0.625 mg 1 daily.
5. Dilantin 100 mg at h.s.

Telephone Consent

PARTICIPANTS:
1. Mary Jones.
2. Dr. Mickey Mouse.
3. John Smith.

PATIENT NAME: XXX.

PATIENT FULL SSN: XXX

CONSENTING PROCEDURE: Persantine thallium.

PROVIDERS NAME AND PAGER NUMBER:
1. Dr. Mickey Mouse.
2. 5555.

NEXT OF KIN NAME/TELEPHONE #/ RELATIONSHIP TO PATIENT:
1. John Smith.
2. 555-555-5555.
3. Son.

CONVERSATION:
Ms. Jones: Dr. Mouse?

Dr. Mouse: Yes, maam.

Ms. Jones: You may begin.

Dr. Mouse: Is this John Smith?

Mr. Smith: Yes.

Dr. Mouse: Son of XXX?

Mr. Smith: Yes.

Dr. Mouse: Mr. Smith, this is Dr. Mickey Mouse. I'm one of the nuclear medicine staff doctors at the XXX. The doctors taking care of your father have asked us to do a stress test on his heart as part of the workup to see if they need to install the implantable defibrillator. What we would do with XXX is bring him down in the morning. We would start by doing a stress test on him. We would use a medication called Persantine that will mimic the effect of exercise by dilating up the arteries around his heart. There is some risk involved in that procedure, and that's what I need the consent from you to do. The risk comes primarily if there is significant blockage in the arteries around his heart or if the bypass graft that he had several years ago have blocked back up. We can, in some patients, cause them to have angina. Very rarely can cause a heart attack or we can cause a problem with a rhythm disturbance such as he's already had. We very rarely can cause wheezing. We can rarely cause the patient's blood pressure and heart rate to drop. In order to try to prevent any significant problems, there is a doctor in the room with him at all times monitoring his EKG, monitoring him, any side effects that he's having, watching his vital signs. There is a medication we can use to stop the test early if we need to. We do occasionally do that. The whole stress test takes about 10 minutes. We give the Persantine over four minutes. At seven minutes, we'll give him a dose of a radioactive drug called thallium, and that thallium will let us take images of the heart muscle, look at the blood flow to different parts of the heart muscle, and then at eight and a half minutes we will give him the aminophylline, the medicine that stops the Persantine from working. We'll then put him on our camera and do a set of pictures. We'll send him back upstairs and then bring him down three hours later, give him another very small dose of the radioactive thallium, take a second set of pictures. We'll look at those pictures. If there is certain abnormality on there, then we may need to bring him back down on Wednesday morning and do a third set of pictures but we do the stress test only one time.

Mr. Smith: Okay.

Dr. Mouse: Do you have any questions?

Mr. Smith: No, I think I've understood everything.

Dr. Mouse: Okay. Do I have your permission to proceed with this?

Mr. Smith: Yes.

Dr. Mouse: Okay and as I mentioned earlier, it does require him to cooperate to some extent. So, I realize that that's been a problem and there is a chance we won't be able to finish this test depending on whether or not he is able to cooperate with us. But, we will give it a try tomorrow.

Mr. Smith: Oh, okay.

Dr. Mouse: And do our best.

Mr. Smith: Okay.

Dr. Mouse: Okay?

Mr. Smith: All right.

Dr. Mouse: All right, Mary, I think that's all we need.

Ms. Jones: Okay, thank you, Mr. Smith.

Mr. Smith: Thank you.

Ms. Jones: You're welcome. Let me get you a dictation number.

Dr. Mouse: Okay. Hang on just a minute, Mr. Smith. Okay?

Mr. Smith: Okay.

Dr. Mouse: Okay, Mary, I'm ready.

Ms. Jones: Okay.

Discharge Summary #2

ADMISSION DIAGNOSIS: Atrial flutter.

DISCHARGE DIAGNOSES: Atrial flutter, chest pain.

HISTORY OF PRESENT ILLNESS: The patient is a 57-year-old female from XXX with a history of paroxysmal atrial flutter, atrial fibrillation for 8 years who had been stable on flecainide. She had a 2D echo in July 2003, which was normal, and apparently a cardiac catheterization, the same month in XXX, it showed normal coronary arteries. After that, the patient had bleeding complications/hematoma. For the 5 weeks before her admission, she was visiting the XXX, had climbed a mountain but later had the acute onset of left sided pleuritic-type chest pain with associated dyspnea. The symptoms began the evening before admission and persisted into the morning. The pain was worse with moving and lying down; and relieved in the sitting position. The patient denied any large extremity edema or pain. No PND or orthopnea. In the ED, the patient was found to be in a rapid atrial flutter. Then her heart rate was as low as the 30’s with a systolic blood pressure in the 70’s, and the patient felt faint and was given atropine and she was admitted for further evaluation and treatment.

PAST MEDICAL HISTORY: Her past medical history includes: Paroxysmal atrial flutter and atrial fibrillation, GERD, pneumothorax 25 years prior.

MEDICATIONS: Her medications were: Plavix 75 mg a day, flecainide 50 mg b.i.d., and pantoprazole 20 mg a day.

ALLERGIES: She had no known drug allergies.

SOCIAL HISTORY: Lives alone. No tobacco. Occasional ETOH. Three cups of coffee a day.

FAMILY HISTORY: Family history was noncontributory.

PHYSICAL EXAMINATION: Upon exam, she was found to have a pulse of 62, a blood pressure of 156/73, oxygen saturation 98% on room air. Afebrile. She appeared well in no acute distress. NECK: There was no JVD. HEART: S1, S2 normal. No S3 or S4. A 2/6 systolic ejection murmur. LUNGS: Clear to auscultation. Extremities without edema. Pedal pulses +2.

LABORATORY: Labs were: Potassium 4.2, BUN 4, creatinine 0.8, glucose 98. Hematocrit 39.8. CK 73/0.7/0.1. Troponin I less than 0.3. LFTs within normal limits. Total cholesterol 201. INR 0.9.

EKG #1: Atrial flutter with variable block with rapid ventricular response. Heart rate is 100 to 150. Normal axis.

EKG #2: With sinus rhythm. Heart rate in the 60’s. Normal axis. No acute ST or T-wave changes.

IMPRESSION: A 45-year-old woman with a history of atrial fibrillation and flutter who presented with acute left pleuritic chest pain and rapid atrial flutter. In her differential diagnosis for the chest pain were pulmonary embolism, was to have a spiral CT of the chest. Acute myocardial infarction which was started, but she was to have serial electrocardiograms and cardiac enzymes. Chest x-ray, there was no evidence of pneumothorax. She was to be admitted to the telemetry service to be started on intravenous heparin. There was no evidence of pericarditis on her electrocardiogram.

It was felt that her subsequent diagnosis would probably be lone atrial flutter. When the patient converted to sinus rhythm, she did have significant bradycardia with hemodynamic instability. It was suspected there was a severe AV block, perhaps as a result of flecainide. It was placed on hold for a short time. She was to have a 2D echo and have her rhythm monitored on telemetry. It was felt she also did have sinus node dysfunction. She was continued on her PTI for her gastroesophageal reflux disease.

The CT of the chest revealed a left pleural based lesion. She had a bump in her troponin I to 3.9, which returned to the baseline, less than 0.3. It was felt her chest pain was pleuritic in nature, that she had an abnormal CT with a left pleural based lesion. She had a history of a normal catheterization, and it was felt that her bump in troponin was most likely a lab error, and she was continued on Plavix. Heparin was discontinued. She was started on Tenormin 25 mg a day. It was felt that should her echo reveal a structurally normal heart, she could restart flecainide. She was to have a pulmonary evaluation. It was doubted that there was any cardiac etiology of her chest pain. She was to eventually return to her cardiologist for consideration of ablation of atrial flutter.

The pulmonary service felt that the left lower lobe lesion most likely represented a scar related to her old spontaneous pneumothorax. It was suggested that she have a repeat CT scan in approximately 3 months, and that she take copies of the films and the CT with her to her physicians and have the new films compared with old.

In telemetry she had no further bouts of atrial flutter. She was asymptomatic. There were no pauses in her rhythm. She was tolerating Tenormin at 25 mg a day. Her physical exam remained unchanged. Echo was to be further evaluated to see if she could restart her flecainide, should the heart be structurally normal. In the meantime she would be continued on Tenormin. She was stable for discharge on XXX on atenolol 25 mg a day, pantoprazole 40 mg a day, and Plavix 75 mg a day.

Discharge Summary #3