DATE OF CONSULTATION: MM/DD/YYYY
REFERRING PHYSICIAN: John Doe, MD
REASON FOR CONSULTATION: Palpitations.
HISTORY OF PRESENT ILLNESS: This is a (XX)-year-old female with a history of hypertension and rare infrequent palpitations over the last year. The patient states over the last four days, she has had significant increase in frequency and intensity of her palpitations. She measured a pulse, which was greater than 120s. Today, she again had an event of prolonged palpitations and became concerned with her elevated heart rate. She came to the emergency department for evaluation of her palpitations. The patient was placed on the monitor and has remained in sinus tachycardia. She was given beta blocker, which improved her tachycardia and improved her symptoms subsequently. The patient denies any history of syncopal episodes or lightheadedness. She denies any chest pain. She has no history of myocardial infarction. She has had no previous workup for palpitations. She denies any history of diabetes mellitus. No dyslipidemia or thyroid disease. Currently, she is without complaints of palpitations, chest pain or shortness of breath.
PAST MEDICAL HISTORY: As noted above.
PAST SURGICAL HISTORY: Percutaneous Achilles tendon lengthening. She denies any other major surgeries.
MEDICATIONS: Benicar 25 mg daily.
ALLERGIES: The patient denies any drug allergies.
FAMILY HISTORY: Mother passed away of a myocardial infarction at age of about 60.
SOCIAL HISTORY: The patient is a nonsmoker. No history of alcohol use. No recreational or injection drug use.
REVIEW OF SYSTEMS: Pertinent review of systems as noted above. Otherwise, 14-point review of systems is negative, but noncontributory.
PHYSICAL EXAMINATION:
GENERAL: This is a very pleasant but mildly anxious appearing (XX)-year-old female who answers questions appropriately, currently in no apparent distress.
VITAL SIGNS: Blood pressure upon ED admission was 142/94, pulse 112, respiratory rate 20, saturation 97% on room air, temperature 97.
HEENT: Normocephalic and atraumatic. Extraocular movements are intact. Pupils are equal, round, and reactive to light.
NECK: Supple. There is no thyromegaly, goiter or lymphadenopathy.
LUNGS: Breath sounds are clear and equal bilaterally.
HEART: Regular rhythm, but tachycardic. There is normal S1 and S2. There are no appreciable murmurs, rubs, or gallops. Cardiac apex is nonpalpable secondary to body habitus.
ABDOMEN: Obese, soft, nontender, and nondistended x4 quadrants with audible bowel sounds. No palpable masses.
EXTREMITIES: Warm without clubbing, edema, or cyanosis.
PERIPHERAL VASCULAR: Radial, carotid, and pedal pulses are 2/4 bilaterally. There are no carotid thrills or bruits.
NEUROLOGIC: Alert and oriented to person, place, and time. No focal deficits.
LABORATORY DATA: WBC is 11.6, H and H 13.2 and 40.4, platelet count 284. Sodium 138, potassium 4.2, BUN 15, creatinine 0.9. Liver panel is within normal limits. Glucose 98. INR is 0.97. Magnesium 2.3. TSH is 1.072. Cardiac enzymes: CK is 160 and 160. CK-MB is 2.6, 3.4, and 3.8. Troponin is 0.01, 0.02, and 0.02.
DIAGNOSTIC DATA: Chest x-ray shows an acute cardiopulmonary disease. Cardiomediastinal silhouette is within normal limits. EKG shows sinus tachycardia at 110 beats per minute. There is normal axis. There are normal intervals. There are no acute ST or T-wave changes. There are no Q waves. EKG from two years ago shows sinus rhythm at 86 beats per minute. Left atrial abnormality, otherwise no significant change.
IMPRESSION:
1. Palpitations, probably sinus tachycardia. TSH is okay. Nonischemic electrocardiogram with troponins negative x3.
2. Hypertension, controlled.
3. Obesity.
RECOMMENDATIONS:
1. Will check a 2-D echocardiogram to rule out structural heart disease.
2. Will continue to follow the patient on telemetry overnight.
3. The patient had been started on low dose beta blocker, agree with this.
4. The patient will eventually need a nuclear perfusion study.
Thank you for consulting us on this patient. We will follow along with you.
