Cardiology - Report 1

Cardiology

TAPE 8A, Report 1

CHART NOTE

This 45-year-old woman went in 4 years ago because of a bad virus infection.  At that time serum cholesterol was 292.  She was given niacin in doses of 2000 mg daily, and it dropped only to 262 with HDL of 62.  Has a 10-year history of reactive hypoglycemia, which has improved with diet and supplements.  Has a 6-month history of insomnia.  Gets “weepy” premenstrually.

ALLERGIES CODEINE.

REVIEW OF SYSTEMS

Has some bloating after meals and excess flatus.  Has urinary frequency and has extremely cold extremities where she has to wear gloves in the house during the winter.

FAMILY HISTORY

Mother had valvular heart disease, colitis, and gallstones.  Father had heart attack and kidney stones.  Brother has stomach problems.  Mother has gluten sensitivity.

HABITS

Drinks coffee and rare alcohol.  Diet is balanced.

ASSESSMENT

1. Borderline hypercholesterolemia with adequate high-density lipoproteins.

2. Reactive hypoglycemia.

3. Insomnia.

4. Premenstrual syndrome.

5. Tinnitus related to diet.

6. Cold extremities and dry skin.

7. Seborrheic dermatitis.

FOOTNOTE

Line 19.  Extreme was changed to extremely (the adjective was changed to an adverb).

Lines 31, 32.  HDL was expanded in the assessment.

Line 36.  Tinnitus related to diet was clearly dictated, but the experienced transcriptionist would probably seek clarification from the dictator.  Tinnitus (ringing or noise in the ear) is often associated with medication.