Sample Type / Medical Specialty: Cardiovascular / Pulmonary

Sample Name: Cardiac Consultation - 1

Description: To evaluate recurrent episodes of uncomfortable feeling in arm at r
est, as well as during exertion.
(Medical Transcription Sample Report)
CHIEF REASON FOR CONSULTATION: Evaluate recurrent episodes of uncomfortable feel
ing in the left upper arm at rest, as well as during exertion for the last one m
onth.
HISTORY OF PRESENT ILLNESS: This 57-year-old black female complains of having pa
in and discomfort in the left upper arm, especially when she walks and after hea
vy meals. This lasts anywhere from a few hours and is not associated with shortn
ess of breath, palpitations, dizziness, or syncope. Patient does not get any che
st pain or choking in the neck or pain in the back. Patient denies history of hy
pertension, diabetes mellitus, enlarged heart, heart murmur, history suggestive
of previous myocardial infarction, or acute rheumatic polyarthritis during child
hood. Her exercise tolerance is one to two blocks for shortness of breath and ea
sy fatigability.
MEDICATIONS: Patient does not take any specific medications.
PAST HISTORY: The patient underwent hysterectomy in 1986.
FAMILY HISTORY: The patient is married, has four children who are doing fine. Fa
mily history is positive for hypertension, congestive heart failure, obesity, ca
ncer, and cerebrovascular accident.
SOCIAL HISTORY: The patient smokes one pack of cigarettes per day and takes drin
ks on social occasions.
ALLERGIES: THE PATIENT IS ALLERGIC TO CODEINE.
REVIEW OF SYSTEMS: Remarkable for heavy snoring, daytime sleepiness, and easy fa
tigability.
PHYSICAL EXAMINATION:
GENERAL: Well-built, well-nourished black female in no acute distress.
VITAL SIGNS: Blood pressure is 120/80. Respirations 18 per minute. Heart rate 70
beats per minute. Patient weighs 226 pounds, height 68 inches. BMI is 34.
HEENT: Head normocephalic. Eyes, no evidence of anemia or jaundice. Oral hygiene
is good.
NECK: Supple. No cervical lymphadenopathy. Carotid upstroke is good. No bruit he
ard over the carotid or subclavian arteries. Trachea in midline. Thyroid not enl
arged. JVP flat at 45.
CHEST: Chest is symmetrical on both sides, moves well with respirations. Vesicul
ar breath sounds heard over the lung fields. No wheezing, crepitation, or pleura
l friction rub heard.
CARDIOVASCULAR SYSTEM: PMI felt in fifth left intercostal space within midclavic
ular line. First and second heart sounds are normal in character. There is no mu
rmur, gallop, or pericardial friction rub heard.
ABDOMEN: Soft. There is no hepatosplenomegaly or ascites. No bruit heard over th
e aorta or renal vessels.
EXTREMITIES: No pedal edema or calf muscle tenderness. Proximal and distal arter
ial pulsations are well felt.
EKG shows normal sinus rhythm, negative T waves in leads 1, aVL, V4-V6.
IMPRESSION:

1.
2.
3.
4.

Abnormal EKG showing diffuse anterior wall ischemia.

Discomfort left upper arm highly suggestive of angina pectoris.
Obesity.
Obstructive sleep apnea syndrome.

PLAN:
1. Stress Myoview SPECT, echocardiogram.
2. Sleep apnea study.
3. Routine blood tests.
4. Patient will be seen again in my office in two weeks.
Keywords: cardiovascular / pulmonary, consultation, abnormal ekg, cardiac consul
tation, ekg, obstructive sleep apnea, stress myoview spect, angina pectoris, ech
ocardiogram, intercostal space, midclavicular line, pain and discomfort, upper a
rm, apnea, chest, sleepiness, arm, heart,