Cardiology - Report 7

Cardiology

TAPE 8A, Report 7

CHART NOTE

The patient is a 67-year-old female who speaks a small amount of English.  Patient was seen in my office for her scheduled office treadmill stress test.  However, on examining the patient and getting the history through an interpreter, we found the patient had a 2-hour chest pressure 2 days prior to the stress test.  An ECG was done in the office, which showed new T wave inversions in the inferior leads.  Patient has had T wave inversions in the anterior-lateral leads in the past, but the new inferior wall
T wave inversions were new.  It was felt since patient had 2-hour chest pain with new ECG changes, she should not have the treadmill.

Patient has been on Inderal 10 mg p.o. b.i.d. for a prior history of hypertension.  She denies any shortness of breath, diaphoresis, PND, or orthopnea.  There is no history of occult bleeding, no history of anemia.

PHYSICAL EXAMINATION

Physical exam revealed blood pressure is 140/90, pulse 60 and regular, respiratory rate 20, unlabored.  Temperature afebrile.  HEENT was within normal limits.  Neck is supple without jugular venous distention, without carotid bruits.  No lymphadenopathy is present.  Chest reveals dry rales in both bases without wheezing or rubs present.  Breath sounds are adequate.  Heart is regular rhythm without murmur, gallop, or rub.  Abdomen is soft, nontender, without organomegaly.  Extremities are without clubbing, cyanosis, or edema.

Electrocardiogram shows a regular sinus rhythm with ST-T wave changes consistent with ischemia versus subendocardial MI.

IMPRESSIONS

1. Atherosclerotic coronary artery disease.

2. Unstable angina.  Rule out myocardial infarction.

FOOTNOTE

Line 14.  Alternative:  Anterolateral.

Lines 24 to 33.  The dictated headings were deleted to maintain consistency.

Line 35.  ST-T wave changes refers to ST segment and T wave changes.  There is no ST wave.

Line 40.  The dictated abbreviation MI was expanded in the Impression for clarity.