Sample Report: ConsultationPosted on:8/25/2005
CONSULTATION NOTE #1
Ivan Cardiology Medical Group
3015, San Jose
PATIENT NAME: MARK, JAMES HIP #: 000000075906
VISIT DATE: 08/10/05 PATIENT CENTER: XXX
FAMILY PHYSICIAN: SMITH, GEORGE REFERRING PHYSICIAN: CHAPPEL, IAN
HISTORY: Mr. James is a 21-year-old male. The patient off late noted that he develops tachyarrhythmias especially at night. He will take his pulse, which ranges between 120 and 150 and this has been noted on several occasions. He has developed chest discomfort as well, non-exertional. He denies slow increase and slow decrease of heart rate.
PAST MEDICAL HISTORY: The patient denies peptic ulcer disease, asthma, COPD, kidney problem, bleeding disorders, diabetes, and hypertension or history of CAD.
ALLERGIES: No known drug allergies.
MEDICATIONS: Xanax, beta-blocker which she was given by neurologist and has not started yet, Ritalin 20 mg p.o. q.d., and Zoloft 100 mg p.o. q.d.
FAMILY HISTORY: Father is status post CABG and heart attack. Mother also has heart disease.
PERSONAL HISTORY: Smokes four cigarettes a day. Works as an office clerk. Denies significant alcohol use.
REVIEW OF SYSTEMS: Noncontributory.
General: He is a well-developed, well-nourished male in no acute distress.
Vital signs: Blood pressure is 100/70 mm Hg. Pulse is 82 per minute and regular. Respiratory rate is 18.
Heart: Regular rate and rhythm. Normal S1 and S2. No murmurs, clicks, rubs or gallops.
Abdominal exam: Normal bowel sounds. Nontender. Nondistended.
Extremities: No clubbing, cyanosis or edema.
Neurologic: Grossly nonfocal.
3. Chest pain.
1. I have recommended Holter monitor for assessment of tachyarrhythmias.
2. The patient will also have stress test for evaluation of exercise-induced arrhythmias.
3. We discussed risk factors for CAD especially smoking cessation and reduction of stimulants.
Robert D. Berman, MD