FINDINGS AND RECOMMENDATIONS OF CONSULTANT:  This is a 69-year-old male with a history of hypertension, chronic atypical chest pain and alcohol abuse, who presents to the hospital with intermittent sharp pain located in the epigastric area that he states is worse with deep inspiration and palpation. This has been going on for a couple of weeks. He reports compliance with his medications at home, but cannot name any of them and does not have any bottles. He does have a history of hypertension and comes in with elevated blood pressure of 152/85, and currently is 156/92. He was previously seen in March 2007 by a local cardiologist and underwent a thallium stress test at that time which was negative for inducible ischemia. Echocardiogram at that time showed normal LV function. He was in the hospital again in June 2007, again with atypical chest pain symptoms, and was ruled out for MI. An ECG was unchanged. Medical management was recommended at that time. His ECG this admission does show a bifascicular block which is unchanged from his baseline ECG. Troponin is 0.06 and 0.05. We are now asked to see the patient from a cardiac standpoint, for further evaluation and treatment.

PAST MEDICAL HISTORY:  Hypertension, heavy alcohol use, throat cancer, status post chemotherapy and radiation 6 years ago. COPD. Abnormal ECG. Prior tobacco abuse. 

PAST SURGICAL HISTORY:  None.

ALLERGIES:  Penicillin, which causes facial edema.

MEDICATIONS:  Unknown.

FAMILY HISTORY:  Negative for premature CAD.

SOCIAL HISTORY:  He is employed part-time at Wal-Mart. He is married. He also does part-time work for a construction company. Prior smoker. He drinks on a daily basis, a half bottle of vodka per day. 

REVIEW OF SYSTEMS:  Positive for epigastric discomfort, atypical chest pain, hypertension, heavy alcohol abuse, prior history of throat cancer. No weight loss or gain. No fevers. No epistaxis. No cough, no hemoptysis, no lung disorders. No orthopnea, lower extremity edema, or syncope. No nausea, vomiting, diarrhea, constipation, or abdominal pain. No hematuria or dysuria. No seizures, headache or vision loss. No claudication. No rashes or pruritus. No muscle or joint aches. No blood disorders or cancers.

PHYSICAL EXAMINATION:  Vital signs showed blood pressure 156/92, pulse 105 and regular, and respiratory rate of 12. In general, this patient is well developed and nourished, and appears well hydrated. Appearance is appropriate to the stated age. The patient is alert, cooperative, and in no acute distress at this time. Skin texture, turgor and pigmentation appear normal for stated age. There is no obvious rashes or cyanosis noted. Head is atraumatic, normocephalic, symmetrical and without deformities. No conjunctival injection or scleral icterus is noted. External ear exam reveals no abnormalities. Nose shows no septal deviation. Turbinates appear normal without hyperemia. Gums are pink, without bleeding. Mucosa is moist. Carotid pulses are equal and adequate bilaterally, with no bruits auscultated. The trachea is midline and freely mobile. There is no JVD. Thyroid is not palpable nor enlarged. The lungs are clear to auscultation without adventitial sounds, rails, rhonchi or wheezes. Breath sounds have good intensity without prolonged expiratory phase. Respirations are normal, with good chest motion.  Heart has regular rate and rhythm, without murmurs. No clicks, gallops, rubs, or extra heart sounds (S3, S4, opening snaps). Heart sounds are of normal intensity.  PMI is in the midclavicular line. Abdominal inspection reveals a soft, nontender abdomen with no masses, organomegaly or rebound tenderness. There are active bowel sounds noted in all 4 quadrants. There are no abdominal pulsations or bruits. No flank pain is elicited. Extremities have no clubbing, cyanosis, or edema. Pulses are equal and adequate in the upper and the lower extremities. There are no cutaneous temperature differences noted bilaterally. No calf tenderness is noted. Neurologically, the patient is oriented times 3. There is good grip strength bilaterally with no involuntary movements. Genitourinary and rectal exams are deferred, not applicable. Mentation is appropriate.

ASSESSMENT:  Uncontrolled hypertension.

CARDIAC PLAN OF TREATMENT:  I feel no further workup is necessary and from a cardiac standpoint, patient can be discharged for outpatient cardiology followup. He was strongly encouraged to quit drinking and to be compliant with medications as well as followup.

Thank you for the opportunity to evaluate your patient's cardiac status.

CRITERIA:  A medium-sized facility, 100% transcribed reports (not speech-recognized). A total of 3 errors, one major.

NUMBER OF ERRORS: 3

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Pati AR Howard has been an MT for 30 years, currently working as a senior MT for Orlando Health (a level I trauma center in Central Florida). She has written many articles, collaborated on reference books and is involved in other areas promoting the profession.

This column has been pre-approved by AHDI for 1 CEC in MT Tools.