Cardiology Case Study 8

Cardiology

TAPE 8B, Report 8

HISTORY AND PHYSICAL EXAMINATION

CHIEF COMPLAINT

Shortness of breath.

HISTORY OF PRESENT ILLNESS

This 60-year-old female has been in good health all of her life.  Two months ago, she awakened complaining of shortness of breath which had lasted all evening.  She was told that she had suffered a myocardial infarction.  The records are currently not available but are being sent for.  The patient was observed for a period of 7 days and was then advised to have a temporary pacemaker followed by a permanent ventricular pacemaker.  Since that time the patient has been discharged and has done very well.  She has had no recurrence of the shortness of breath.  There has never been any chest pain described.  The patient has been somewhat fatigued and has been limited in what she can do, mainly because they were not advised what kind of activities were safe for her.  She has also noted pain in her axilla from the permanent pacemaker site.  She has had no recurrence of feeling short of breath similar to what brought her into the hospital originally.

PAST MEDICAL HISTORY

Illnesses:  None.  Surgery:  None.

MEDICATIONS

Isordil 5 mg q.i.d.

ALLERGIES

None known.

FAMILY HISTORY

There is no family history of early heart disease.

REVIEW OF SYSTEMS

Review of systems was essentially negative.  The patient has had some cramping in her legs and in her arms.

SOCIAL HISTORY

The patient does not drink or smoke.

PHYSICAL EXAMINATION

VITAL SIGNS:  Blood pressure 170/94 in the right arm and 140/90 in the left arm.  The weight is 154-1/2 pounds with shoes off.

HEENT:  Head, eyes, ears, nose, and throat are unremarkable.

NECK:  No jugular venous distention.  The carotids are 2+ without bruits.  The thyroid is not enlarged.

CHEST:  The chest is clear to percussion and auscultation.

HEART:  The PMI is not palpable.  The heart is without gallop, rub, or murmur.

ABDOMEN:  Abdomen is negative.

EXTREMITIES:  Extremities are negative.

The chest wall reveals that the pacemaker site is over the left axilla, which is causing some local discomfort in this region.

IMPRESSION

1. Status post myocardial infarction.

2. Permanent ventricular pacing.

RECOMMENDATION

The patient was advised to undergo a chest x-ray, a CBC, and return for a treadmill stress test.  At that time further recommendations as far as activity level will be made.  The patient could probably benefit from AV sequential or AV synchronous pacing.  She could also benefit from a relocation of her pacemaker site out of the axilla.  These will be discussed as time goes by.

FOOTNOTE

Line 12 (Page 1).  Awokened (not a word) was changed to awakened.

Line 46 (Page 1).  Exam was expanded in the heading.

Line 49 (Page 1).  The subheading HEENT was added.

Lines 9-10 (Page 2).  Alternative:  The sentence regarding the chest wall is an addendum to the chest examination and could be added to Line 3 on the same page.

Line 20 (Page 2).  AV (atrioventricular) sequential or synchronous pacing, not arteriovenous.