CARDIOLOGY TEST FILES

CARDIO_T1 cardio-T1(voice)

HISTORY AND PHYSICAL EXAMINATION

CHIEF COMPLAINT:  Pain in the chest.

HISTORY OF PRESENT ILLNESS:  This is a 40-year-old gentleman referred to this office because of pain in the chest.  He states that this pain has been present in the area for some time.  The pain is radiating in nature, and the patient is worried about it.

PAST MEDICAL HISTORY:  There is no diabetes or history of rheumatic fever in the past.  The patient says, “I’m really pretty healthy”.

SOCIAL HISTORY:  He is a 1-pack-a-day cigarette smoker.  EtOH intake is negative.

FAMILY HISTORY:  His parents both died as a result of strokes.  There is no known family history of heart disease.

PHYSICAL EXAMINATION

NECK:  The neck is supple.  There are no carotid bruits.

CHEST:  Lungs are clear to percussion and auscultation.

HEART:  PMI is not displaced.  PMI is in the fifth intercostal space.  There is no thrill, heave, gallop, rub, or murmur.

LABORATORY DATA:  The electrocardiogram is within normal limits.

The patient was subjected to a treadmill stress test.  Using the protocol of Ellestad, he reached a maximum pulse rate of 150, which was 93% of his maximum predicted heart rate.  There were no abnormalities noted before the exam, there were no abnormalities noted during the exam, nor after the exam.  He had a good response to all phases of this testing.

DIAGNOSES

1.  Chest pains, not on a cardiac basis.

2.  Possible musculoligamentous sprain in the costal area.

3.  Some risk factors for cardiovascular disease, including heavy cigarette smoking.

DISCUSSION:  I find no frank evidence of cardiac problems in this gentleman.  However, I believe with some modification of his lifestyle, including the discontinuation from smoking and losing several pounds of weight, he can enjoy good health for many years.  As noted above, his treadmill stress test was interpreted as being completely normal.  The patient’s present episodes of chest pain are probably only on a musculoskeletal basis and are to be treated with oral analgesics such as aspirin or perhaps Parafon Forte.




CARDIO_T2 cardio-T2(voice)

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 an elevated blood pressure, and he was advised to start a low-fat, and a low-salt diet at that time.

He did not go back to his doctor for follow-up blood pressure measurements. He also recalls having 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 2 of the exercise test, and 1 mm horizontal ST segment depression in lead V5 at stage 3 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 include blood pressure 174/94.  Pulse 76,regular.  Respirations are normal.  Neck reveals 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 is clear to percussion and auscultation.  Cardiovascular reveals 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.

ASSSESSMENT: 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 3 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’s to return to my office in 2 weeks to assess the patien’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.