Cardiology - Report 3

Cardiology

TAPE 8A, Report 3

INITIAL OFFICE EVALUATION

This 58-year-old female noted a sensation of “shortness of breath” in the high substernal region of the chest.  She also describes this as a feeling of “heaviness” or “pressure”.  I believe that this sensation is more consistent with angina than true air hunger.  The sensation lasted about 20 minutes.  The patient did not have any radiation of her discomfort, and there were no associated symptoms, other than the shortness of breath as described.

PHYSICAL EXAMINATION

Neck:  The neck is supple without masses.  The thyroid gland is not enlarged.  The carotid arterial pulsations are equal and full.  There are prominent, normal jugular venous pulsations with the patient in the supine position.  There is a venous hum on the left, which obliterates easily with minimal pressure on the neck.

Chest:  The chest is symmetric with equal respiratory excursions.  There is no thoracic deformity or tenderness.  The breasts are normal and free of masses or tenderness.  Heart:  There is no visible or palpable precordial activity.  The first heart sound is normal in character and intensity.  The second heart sound is also normal in intensity, but I was unable to appreciate splitting of the second sound.  No third or fourth sound was present.  The cardiac rhythm is regular, and there is a grade 3/6 systolic ejection murmur that is loudest at the second left intercostal space.  This murmur decreases in intensity markedly with Valsalva maneuver.  The murmur does not radiate to the neck.

Lungs:  The lungs are clear to auscultation and percussion, and diaphragmatic motion appears normal.  Extremities:  The extremities are free of cyanosis, clubbing, or peripheral edema.  There are bilateral soft femoral bruits.  The left femoral artery has a 4+ pulsation, and the right femoral artery has only a 1+ pulsation.  Nevertheless, the more distal pulses are normal and symmetric, including the popliteals, dorsalis pedis, and posterior tibial pulses.

ELECTROCARDIOGRAM

The ECG reveals normal sinus rhythm.  There are T wave inversions that are symmetric in leads V1 through V3, and lead V4 has a very flat T wave.  This pattern is consistent with anterior myocardial ischemia.

ASSESSMENT

1. This patient has a history which is consistent with angina pectoris.  This is associated with an abnormal electrocardiogram that is apparently changed from a previous tracing.  The ECG reveals T wave abnormalities consistent with anterior myocardial ischemia.  I think that it would be appropriate to perform cardiac catheterization rather than stress testing, since the electrocardiogram has already shown us signs of ischemic heart disease.

2. The patient also has a rather loud heart murmur which may be functional, but I have ordered an echocardiogram to see if this can be further defined.

FOOTNOTE

Line 34 (Page 1).  The heading “Lungs” was added to maintain consistency.

Lines 1 to 11 (Page 2).  The assessment was enumerated for clarity.