Cardiology - Report 2

Cardiology

TAPE 8A, Report 2

LETTER

Date

Name

Address

City, State, Zip

Re:

Dear Sirs

Mr. (blank) was admitted at 1700 hours after having had an episode of weakness following GI bleeding approximately 3 weeks earlier.  He was seen by the ambulance people and was in a rapid heartbeat, the exact nature of which we do not know, but at any rate Xylocaine was started, and by the time he reached the emergency room, his heart rate was between 75 and 80 with a sinus rhythm.  He had excellent ST segments and upright T waves.

When I saw him, his blood pressure was 166/88.  His pulse was 75 with a regular sinus rhythm.  He had a good carotid pulse bilaterally.  His lungs were clear.  The heart was not enlarged.  There were no murmurs.

He was started on a cardiac monitor.  A chemistry panel was drawn, and the only abnormal finding was a BUN of 22.4.

He was observed closely for any ST or T wave change, and there was none.  He had no episode of hypotension.  There was no reason to do any cardiac enzyme studies.  He did have a followup upper GI done because of his bleeding in late June, and this was reported as negative.

There was no further pain, there was no further arrhythmia, and at no time were there any ST or T wave changes present.  I had no reason to do cardiac enzymes, and when I found that his GI tract was stable and that his upper GI did not reveal any new bleeding and there was no drop in his hemogram, I discharged this patient to be followed by his regular physician.

I hope this information will be of help.

Sincerely,

Name.

FOOTNOTE

Line 13 (Page 1).  Re was not dictated but was added to demonstrate proper letter format.

Line 33 (Page 1).  ST means ST segment in the phrase ST or T wave change, a phrase commonly dictated by physicians.  There is no ST wave.