Cardiology Case Study 3

Cardiology

TAPE 8B, Report 3

CONSULTATION

HISTORY

History reveals that this patient has a longstanding history of arteriosclerotic and hypertensive heart disease.  She has had chronic atrial fibrillation and has a pacemaker implanted.  She has chronic hypertension.  She has had angina in the past.  However, no documented history of myocardial infarction.  She states that over the past 2 to 3 weeks she has been having increasing shortness of breath.  This apparently has been increasing and last night reached a peak where she was markedly short of breath and dyspneic.  She has had angina in the past but no documented history of myocardial infarction.  No known history of valvular heart disease and no previous congestive heart failure.

MEDICATIONS

Digoxin 0.125 mg daily, Inderal 10 mg b.i.d., Lasix, potassium, Coumadin 2 mg daily because of her chronic atrial fibrillation, Restoril, Metamucil, Voltaren, Capoten.  She is also on transdermal nitroglycerin.

PHYSICAL EXAMINATION

Neck:  Both carotids are palpable.  Volume seems to be diminished, particularly over the left.  No definite bruit at this time.  Jugular neck veins are distended 2 to 3 fingerbreadths above the sternal notch at 30 degrees.  No thyromegaly or adenopathy.  Lungs:  Lungs show diminished breath sounds in both bases, perhaps greater on the right than the left.  She does have bibasilar rales throughout both lung fields.  She does have a dorsal kyphosis.  Heart:  Heart sounds are irregularly irregular with a grade 2/6 to 3/6 blowing systolic murmur.  No other gallops or rubs.  No diastolic rumble.

IMPRESSION

1. Congestive heart failure, probably on the basis of combined arteriosclerotic and hypertensive heart disease.  Doubt significant valvular heart disease.

2. Chronic atrial fibrillation secondary to arteriosclerotic and hypertensive heart disease.

3. Right-sided pleural effusion, most likely on the basis of congestive heart failure.  However, need to consider other inflammatory processes, such as pneumonitis and perhaps also the possibility of neoplasm.

This patient will be admitted to the hospital and monitored.

Thank you very much for this consultation.

FOOTNOTE

Lines 13, 30 (Page 1).  Alternative:  2-3.

Line 27 (Page 1).  The brief form was expanded in the heading.

Lines 37, 38 (Page 1).  The dictation two to three over six is presented in numerals thus:  2/6 to 3/6.