CARDIOLOGY FILES

CARDIO_2


HISTORY AND PHYSICAL EXAMINATION

CHIEF COMPLAINT:  Precordial-type squeezing chest pain radiating to left shoulder and left arm, unrelieved for approximately 24 hours’ duration.

PRESENT ILLNESS:  This 68-year-old Caucasian male with a history of hypertension and congestive heart failure was apparently in good health, although he had failed to follow up on his office appointments and ran out of refills on probably his Lasix 1 week ago.  The patient shortly thereafter had some slight precordial chest pain which resolved.  The precordial chest pain returned again.  The patient obtained good relief with nitroglycerin sublingual.  The Patient has also been on Calan and Micro-K, which he has continued to take.  He has had no chills or fever, no nausea, emesis, or diarrhea, no unusual color change.  He did complain of being somewhat diaphoretic and dizzy with the chest pain.

FAMILY HISTORY:  No familial diseases known.

PERSONAL HISTORY:  Patient is known to imbibe alcohol and perhaps to excess on occasion.  He does not smoke.

PAST MEDICAL HISTORY:  Patient has had an appendectomy, a tonsillectomy, and an umbilical herniorrhaphy.

SYSTEM REVIEW:  System review essentially negative.

PHYSICAL EXAMINATION

VITAL SIGNS:  Blood pressure 160/110, respirations 20, pulse 87, temperature 98.

GENERAL APPEARANCE:  A slightly obese, well-developed 68-year-old Caucasian male.

HEENT:  Head symmetrical.  Pupils equal, react to light and accommodation.  No scleral icterus.  Ears, nose, and throat clear.  Mouth moist.

NECK:  Supple, no masses.  Normal anterior carotid pulsations bilaterally.

CHEST:  Clear to P&A.

CARDIOVASCULAR:  Distant heart tones.  No murmurs.  Good peripheral pulses, including dorsalis pedis.

ABDOMEN:  Protuberant.  No masses.  Active bowel sounds.

GENITALIA:  Normal male.

RECTAL:  Deferred.

EXTREMITIES:  Negative x 4.  No ankle edema.

NEUROLOGICAL:  Physiologic.

IMPRESSION

1.  Probable angina pectoris.

2.  Rule out MI (myocardial infarction).

3.  Congestive heart failure, compensated.

4.  Hypertension.

5.  Arteriosclerotic heart disease.



CARDIO_3

CHART NOTE

A hypertensive male with a pacemaker placed, who is complaining tonight of a period of blackout that occurred approximately a half hour before arrival here and unheralded by any prior symptoms.  He did not have chest pain, shortness of breath, or cough prior to his syncope.  This happened once before and resulted in the placement of a cardiac pacemaker.

He has in the past 2 weeks experienced several episodes of mild lightheadedness for which he is being treated with Antivert 25 mg t.i.d.  He takes a blood pressure medicine that he cannot name.  His pacemaker was checked for function this week and found to be functioning satisfactorily.

PHYSICAL EXAMINATION:  A well-developed, well-nourished male in no apparent distress.  His blood pressure is 120/84, pulse 88, respiratory rate 20, and temperature 99.6.  He is alert and well oriented and has normal pupils.  There is no ataxia.  The neck is nontender.  The lungs are clear, and the heart has a regular sinus rhythm without murmurs.  The pacemaker is palpable in the left pectoral region.  The abdomen is nontender, soft, and has normal bowel sounds.  There is no pretibial edema.

LABORATORY FINDINGS:  The patient’s ECG was normal.  The BUN was 18 and the CPK 67; the glucose was 156.  His potassium was 5.0 and sodium 136; chloride was 102 and total CO2 27.  The white count was 10,500 with 3% bands and 76% segs.  The hematocrit was 50.

It was elected to admit the patient to the CCU for observation and for reevaluation of his pacemaker.

DIAGNOSES

1.  Arterial hypertension.

2.  Probable pacemaker malfunction.



CARDIO_4

HISTORY AND PHYSICAL EXAMINATION

CHIEF COMPLAINT:  Shortness of breath.

HISTORY OF PRESENT ILLNESS:  This 60-year-old female has been in good health all of her life.  Two months ago she awakened complaining of shortness of breath which had lasted all evening.  She was told that she had suffered a myocardial infarction.  The records are currently not available but are being sent for.  The patient was observed for a period of 7 days and was then advised to have a temporary pacemaker followed by a permanent ventricular pacemaker.  Since that time the patient has been discharged and has done very well.  She has had no recurrence of the shortness of breath.  There has never been any chest pain described.  The patient has been somewhat fatigued and has been limited in what she can do, mainly because they were not advised what kind of activities were safe for her.  She has also noted pain in her axilla from the permanent pacemaker site.  She has had no recurrence of feeling shortness of breath similar to what brought her into the hospital originally.

PAST MEDICAL HISTORY:  Illnesses:  None.

Surgery:  None.

MEDICATIONS:  Isordil 5 mg q.i.d.

ALLERGIES:  None known.

FAMILY HISTORY:  There is no family history of early heart disease.

REVIEW OF SYSTEMS:  Review of systems was essentially negative.  The patient has had some cramping in her legs and in her arms.

SOCIAL HISTORY:  The patient does not drink or smoke.

PHYSICAL EXAMINATION

VITAL SIGNS:  Blood pressure 170/94 in the right arm and 140/90 in the left arm.  The weight is 154-1/2 pounds with shoes off.

HEENT:  Head, eyes, ears, nose, and throat are unremarkable.

NECK:  No jugular venous distention.  The carotids are 2+ without bruits.  The thyroid is not enlarged.

CHEST:  The chest is clear to percussion and auscultation.

HEART:  The PMI is not palpable.  The heart is without gallop, rub, or murmur.

ABDOMEN:  Abdomen is negative.

EXTREMITIES:  Extremities are negative.

The chest wall reveals that the pacemaker site is over the left axilla, which is causing some local discomfort in this region.

IMPRESSION

1.  Status post myocardial infarction.

2.  Permanent ventricular pacing.

RECOMMENDATION:  The patient was advised to undergo a chest x-ray, a CBC, and return for a treadmill stress test.  At that time further recommendations as far as activity level will be made.  The patient could probably benefit from AV sequential or AV synchronous pacing.  She could also benefit from a relocation of her pacemaker site out of the axilla.  These will be discussed as time goes by.



CARDIO_5

HISTORY AND PHYSICAL EXAMINATION

CHIEF COMPLAINT:  Shortness of breath.

HISTORY OF PRESENT ILLNESS:  This 60-year-old female has been in good health all of her life.  Two months ago she awakened complaining of shortness of breath which had lasted all evening.  She was told that she had suffered a myocardial infarction.  The records are currently not available but are being sent for.  The patient was observed for a period of 7 days and was then advised to have a temporary pacemaker followed by a permanent ventricular pacemaker.  Since that time the patient has been discharged and has done very well.  She has had no recurrence of the shortness of breath.  There has never been any chest pain described.  The patient has been somewhat fatigued and has been limited in what she can do, mainly because they were not advised what kind of activities were safe for her.  She has also noted pain in her axilla from the permanent pacemaker site.  She has had no recurrence of feeling shortness of breath similar to what brought her into the hospital originally.

PAST MEDICAL HISTORY:  Illnesses:  None.

Surgery:  None.

MEDICATIONS:  Isordil 5 mg q.i.d.

ALLERGIES:  None known.

FAMILY HISTORY:  There is no family history of early heart disease.

REVIEW OF SYSTEMS:  Review of systems was essentially negative.  The patient has had some cramping in her legs and in her arms.

SOCIAL HISTORY:  The patient does not drink or smoke.

PHYSICAL EXAMINATION

VITAL SIGNS:  Blood pressure 170/94 in the right arm and 140/90 in the left arm.  The weight is 154-1/2 pounds with shoes off.

HEENT:  Head, eyes, ears, nose, and throat are unremarkable.

NECK:  No jugular venous distention.  The carotids are 2+ without bruits.  The thyroid is not enlarged.

CHEST:  The chest is clear to percussion and auscultation.

HEART:  The PMI is not palpable.  The heart is without gallop, rub, or murmur.

ABDOMEN:  Abdomen is negative.

EXTREMITIES:  Extremities are negative.

The chest wall reveals that the pacemaker site is over the left axilla, which is causing some local discomfort in this region.

IMPRESSION

1.  Status post myocardial infarction.

2.  Permanent ventricular pacing.

RECOMMENDATION:  The patient was advised to undergo a chest x-ray, a CBC, and return for a treadmill stress test.  At that time further recommendations as far as activity level will be made.  The patient could probably benefit from AV sequential or AV synchronous pacing.  She could also benefit from a relocation of her pacemaker site out of the axilla.  These will be discussed as time goes by.

CARDIO_6

ADMISSION NOTE

CHIEF COMPLAINT:  The patient is a 53-year-old female who was brought to the emergency room with chief complaint of chest pain.

HISTORY OF PRESENT ILLNESS:  The patient has a history of atherosclerotic coronary artery disease, having undergone an angioplasty.  She had a catheterization done which showed less than 50% blockages of several vessels.  Since that time the patient has had, off and on, a midchest pressure that sometimes she felt was due to esophageal spasm and sometimes to angina.

On this occasion the patient was restless at night in bed, not under any particular stress or exertion, when she began to have left substernal chest pressure radiating to her left shoulder, down her left arm, into her left neck, and into her left jaw.  She felt the radiations represented angina.  She took 3 nitroglycerin tablets with some relief, but the chest pressure persisted.

MEDICATIONS:  It should be noted that the patient has been off her nitro patch for approximately 2 weeks.  She had been taking her other medications which included Elavil, Moduretic, Mevacor, Persantine, Cardizem 30 mg q.i.d., Reglan, and probably Zantac.

PHYSICAL EXAMINATION

GENERAL:  Physical exam in the ER showed a well-developed, well-nourished 53-year-old female in no acute distress.  Blood pressure 124/86, pulse 84 and regular, respiratory rate 20 and unlabored, temperature 96.5.

HEENT:  Within normal limits.

NECK:  Supple without jugular venous distention.

CHEST:  Clear to auscultation.

HEART:  Regular rhythm without murmur, gallop, or rub.  Chest wall nontender.

ABDOMEN:  Soft, nontender.

Bowel sounds normal.

EXTREMITIES:  Without clubbing, cyanosis, or edema.

EMERGENCY ROOM COURSE:  An I.V. of D5W TKO was started.  An electrocardiogram was obtained which showed ischemic ST and T wave changes without any infarct changes noted.  CBC and total CPK were drawn.  CBC showed a white count of 8.8 with 55 segs, 5 bands, 33 lymphs, 5 monocytes, hemoglobin 13.3, hematocrit 39.8.  CPK 57.  Admission chest x-ray was done.  The lung fields were without signs of congestive heart failure or infiltrate.  Heart was normal size.  Nitro paste 1 inch was placed to the chest.

The patient was given Procardia 10 mg p.o., nasal oxygen at 3 liters by nasal cannula.  Morphine sulfate was given, 2 mg I.V.  It was agreed to admit the patient to the CCU with the following diagnosis.

DIAGNOSIS:  Unstable angina.  Rule out subendocardial myocardial infarction (MI).