Cardiology
TAPE 8B, Report 12
INITIAL OFFICE EVALUATION
A 47-year-old white male who has been experiencing about 5 to 6 episodes of dizziness per week. The entire episode lasts only about 5 to 6 seconds. He has never fallen and recovers after he stops his activity for a few seconds. A Holter monitor, stress test, and carotid flow study were all normal. He denies chest pain or shortness of breath. He experiences headaches occurring 2 to 3 times per day, and this has been present for years. Procardia was prescribed and the headaches improved.
PHYSICAL EXAMINATION
This is a well-developed, well-nourished white male. He answers all questions promptly and appropriately. He has a normal, brisk, unaided gait. Examination of the eyes reveals pupils that react to light in a normal manner. The optic fundi are normal. His extraocular motions are normal, and there is no nystagmus. The neck does not reveal any goiter, adenopathy, or venous distention. The lungs are clear to percussion and auscultation. The heart reveals normal borders to percussion without evidence of cardiomegaly. There is a regular rhythm at a rate of 84, and there is no gallop or arrhythmia. There is a grade 2 to 3,
low-pitched aortic ejection systolic murmur, heard best during expiration. The murmur is moderately low pitched. A2 is loud. The blood pressure in the right arm, supine, is 156/114. Repeat blood pressure in the right arm is 156/116. The abdomen is soft, scaphoid, and nontender. There is no mass or organ enlargement. He is able to balance himself normally on 1 foot. The Romberg test is negative. There appeared to be no problem with coordination.
low-pitched aortic ejection systolic murmur, heard best during expiration. The murmur is moderately low pitched. A2 is loud. The blood pressure in the right arm, supine, is 156/114. Repeat blood pressure in the right arm is 156/116. The abdomen is soft, scaphoid, and nontender. There is no mass or organ enlargement. He is able to balance himself normally on 1 foot. The Romberg test is negative. There appeared to be no problem with coordination.
DIAGNOSES
1. Hypertensive cardiovascular disease, not under treatment or control.
2. Aortic stenosis is a consideration because of the murmur, but it is unlikely because of the lack of associated findings.
3. There is no apparent explanation for the complaint of brief headaches and dizziness.
FOOTNOTE
Lines 7, 9. Alternative: 5-6.
Lines 13, 26. Alternative: 2-3.
Line 28. A2 (heart sound) is aortic valve closure.
Lines 36 to 42. The diagnoses were enumerated.
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