Cardiology
TAPE 8B, Report 7
CHART NOTE
A hypertensive male with a pacemaker placed, who is complaining tonight of a period of blackout that occurred approximately a half hour before arrival here and unheralded by any prior symptoms. He did not have chest pain, shortness of breath, or cough prior to his syncope. This happened once before and resulted in the placement of a cardiac pacemaker. He has, in the past 2 weeks, experienced several episodes of mild lightheadedness for which he is being treated with Antivert 25 mg t.i.d. He takes a blood pressure medicine that he cannot name. His pacemaker was checked for function this week and found to be functioning satisfactorily.
PHYSICAL EXAMINATION
A well-developed, well-nourished male in no apparent distress. His blood pressure is 120/84, pulse 88, respiratory rate 20, and temperature 99.6. He is alert and well oriented and has normal pupils. There is no ataxia. The neck is nontender. The lungs are clear, and the heart has a regular sinus rhythm without murmurs. The pacemaker is palpable in the left pectoral region. The abdomen is nontender, soft, and has normal bowel sounds. There is no pretibial edema.
LABORATORY FINDINGS
The patient’s ECG was normal. The BUN was 18 and the CPK 67; the glucose was 156. His potassium was 5.0 and sodium 136; chloride was 102 and total CO2 27. The white count was 10,500 with 3% bands and 76% segs. The hematocrit was 50.
It was elected to admit the patient to the CCU for observation and for reevaluation of his pacemaker.
DIAGNOSES
1. Arterial hypertension.
2. Probable pacemaker malfunction.
FOOTNOTE
Line 22. Is was added to improve grammar.
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