Cardiology - Report 6

Cardiology

TAPE 8A, Report 6

CONSULTATION

It was my pleasure to see this very pleasant 58-year-old white male for evaluation of chest tightness.  He has had symptoms of tightness across the anterior chest which occasionally will radiate into both the right and left pectoralis areas and into the shoulders.

The patient does have multiple risk factors for coronary artery disease.  He was told 8 years ago that he had elevated blood pressure, and he was advised to start a low-fat, low-salt diet at that time.  He did not go back to his doctor for followup blood pressure measurements.  He also recalls having an elevated cholesterol at that time.  More recently, he had a blood pressure of 168/96 when he was seen at your office for a treadmill exercise test.  He smoked 2 packs a day for some 30 years but stopped 6 years ago following his retirement.  A recent cholesterol was 268.

I did review the treadmill exercise test from your office.  I agree that the patient had a positive treadmill exercise test with symptoms of typical angina pectoris starting at stage II of the exercise test, and 1-mm horizontal ST segment depression in lead V5 at stage III of the exercise test.

PAST MEDICAL HISTORY

The patient has had probable hypertension and hypercholesterolemia of 8 years’ duration.  He was told that he had some narrowing of the carotid arteries several years ago when he was initially seen by you.

The patient has had no previous surgery.

PHYSICAL EXAMINATION

Vital signs:  Blood pressure 174/94.  Pulse 76, regular.  Respirations are normal.  Neck:  There is a soft bruit over the entire right carotid artery and a soft bruit at the base of the left carotid artery.  There are no bruits over the subclavian arteries.  Chest:  Clear to percussion and auscultation.

Cardiovascular:  The PMI is in the fifth left intercostal space at the MCL (midclavicular line).  The LV (left ventricular) impulse is normal.  The rhythm is regular with no premature beats.  S1 and S2 are normal.  There was no S3, S4, or gallop.  There is a soft grade 2/6 systolic ejection murmur heard at the second right and left intercostal space, left sternal border, and cardiac apex.  There is no diastolic murmur.

ASSESSMENT

The patient is a 58-year-old white male who has stable angina pectoris for 3 years’ duration.  His symptom of substernal tightness, which occurs with exertion and which is relieved promptly by rest, is typical of angina pectoris.  This is confirmed by your treadmill exercise test which shows definite
ST segment abnormalities consistent with myocardial ischemia at stage III of the exercise test.  In addition, the patient has multiple risk factors including hypertension, hypercholesterolemia, and past history of smoking.

I believe the patient should be given a trial of medical therapy for angina pectoris.  I anticipate that the patient will have a good response to medical therapy and that he has a relatively good prognosis.  I have started the patient on Cardizem 60 mg p.o. t.i.d., which may be increased to a higher dose if he is able to tolerate the medications.  This would be helpful for treatment of both the angina pectoris and hypertension.  The patient is already taking aspirin 3 times a week when he plays golf, and this would be sufficient.  It may be necessary to add other antihypertensive medications for better control of his blood pressure.  I have asked the patient to return to my office in 2 weeks to assess the patient’s tolerance to the medication and to see if he is having adequate antianginal response.

If the patient continues to have symptoms of exertional angina pectoris on good antianginal medical therapy, then I would be much more concerned that the patient has significant high-grade stenosis, and he should undergo a coronary angiography study at that time.

FINAL IMPRESSION

1. Stable angina pectoris.

2. Hypertension.

3. Atherosclerotic peripheral vascular disease.

Again, thank you for asking me to see this patient in consultation.

FOOTNOTE

Line 20 (Page 1).  Pack was changed to packs for plural agreement.

Line 39 (Page 1).  The abbreviation BP was expanded to blood pressure for clarity.  Some facilities allow the use of BP for blood pressure if the physician dictates it.

Line 43 (Page 1).  Is was changed to are for subject-verb agreement.

Lines 45, 46 (Page 1).  The abbreviation CVS was expanded in the heading.  Other uncommon abbreviations were expanded for clarity.

Line 2 (Page 2).  Murmurs was changed to murmur for subject-verb agreement.