Sample Type / Medical Specialty: Cardiovascular / Pulmonary

Sample Name: Cardiac Consultation - 6

Description: Preoperative cardiac evaluation in the patient with chest pain in t
he setting of left hip fracture.
(Medical Transcription Sample Report)
INDICATIONS: Preoperative cardiac evaluation in the patient with chest pain in t
he setting of left hip fracture.
HISTORY OF PRESENT ILLNESS: The patient is a 78-year-old white female with no pr
ior cardiac history. She sustained a mechanical fall with a subsequent left femo
ral neck fracture. She was transferred to XYZ Hospital for definitive care. In t
he emergency department of XYZ, the patient described six to seven seconds of sh
arp chest pain without radiation, without associated symptoms. Electrocardiogram
was obtained, which showed nonspecific ST-segment flattening in the high latera
l leads I, aVL. She also had a left axis deviation. Serial troponins were obtain
ed. She has had four negative troponins since admission. Due to age and chest pa
in history, a cardiology consultation was requested preoperatively.
At the time of my evaluation, the patient complained of left hip pain, but no ch
est pain, dyspnea, or symptomatic dysrhythmia.
PAST MEDICAL HISTORY:
1. Mesothelioma.
2. Recurrent urinary tract infections.
3. Gastroesophageal reflux disease/gastritis.
4. Osteopenia.
5. Right sciatica.
6. Hypothyroidism.
7. Peripheral neuropathy.
8. Fibromyalgia.
9. Chart review also suggests she has atherosclerotic heart disease and pneumoth
orax. The patient denies either of these.
PAST SURGICAL HISTORY:
1. Tonsillectomy.
2. Hysterectomy.
3. Appendectomy.
4. Thyroidectomy.
5. Coccygectomy.
6. Cystoscopies times several.
7. Bladder neck resuspension.
8. Multiple breast biopsies.
ALLERGIES: NO KNOWN DRUG ALLERGIES.
MEDICATIONS: At the time of evaluation include, 1. Cefazolin 1 g intravenous (IV
). 2. Morphine sulfate. 3. Ondansetron p.r.n.
OUTPATIENT MEDICATIONS: 1. Robaxin. 2. Detrol 4 mg q.h.s. 3. Neurontin 300 mg p.
o. t.i.d. 4. Armour Thyroid 90 mg p.o. daily. 5. Temazepam, dose unknown p.r.n.
6. Chloral hydrate, dose unknown p.r.n.
FAMILY HISTORY: Mother had myocardial infarction in her 40s, died of heart disea
se in her 60s, specifics not known. She knows nothing of her father's history. S
he has no siblings. There is no other history of premature atherosclerotic heart
disease in the family.
SOCIAL HISTORY: The patient is married, lives with her husband. She is a lifetim

e nonsmoker, nondrinker. She has not been getting regular exercise for approxima
tely two years due to chronic sciatic pain.
REVIEW OF SYSTEMS:
GENERAL: The patient is able to walk one block or less prior to the onset of sig
nificant leg pain. She ever denies any cardiac symptoms with this degree of exer
tion. She denies any dyspnea on exertion or chest pain with activities of daily
living. She does sleep on two to three pillows, but denies orthopnea or paroxysm
al nocturnal dyspnea. She does have chronic lower extremity edema. Her husband s
tates that she has had prior chest pain in the past, but this has always been at
tributed to gastritis. She denies any palpitations or tachycardia. She has remot
e history of presyncope, no true syncope.
HEMATOLOGIC: Negative for bleeding diathesis or coagulopathy.
ONCOLOGIC: Remarkable for past medical history.
PULMONARY: Remarkable for childhood pneumonia times several. No recurrent pneumo
nias, bronchitis, reactive airway disease as an adult.
GASTROINTESTINAL: Remarkable for past medical history.
GENITOURINARY: Remarkable for past medical history.
MUSCULOSKELETAL: Remarkable for past medical history.
CENTRAL NERVOUS SYSTEM: Negative for tic, tremor, transient ischemic attack (TIA
), seizure, or stroke.
PSYCHIATRIC: Remarkable for history of depression as an adolescent, she was hosp
italized at State Mental Institution as a young woman. No recurrence.
PHYSICAL EXAMINATION:
GENERAL: This is a well-nourished, well-groomed elderly white female who is appr
opriate and articulate at the time of evaluation.
VITAL SIGNS: She has had a low-grade temperature of 100.4 degrees Fahrenheit on
11/20/2006, currently 99.6. Pulse ranges from 123 to 86 beats per minute. Blood
pressure ranges from 124/65 to 152/67 mmHg. Oxygen saturation on 2 L nasal cannu
la was 94%.
HEENT: Exam is benign. Normocephalic and atraumatic. Extraocular motions are int
act. Sclerae anicteric. Conjunctivae noninjected. She does have bilateral arcus
senilis. Oral mucosa is pink and moist.
NECK: Jugular venous pulsations are normal. Carotid upstrokes are palpable bilat
erally. There is no audible bruit. There is no lymphadenopathy or thyromegaly at
the base of the neck. There is a well-healed scar at the base of the neck. Card
iothoracic contour is normal.
LUNGS: Limited to anterior auscultation only, which was clear.
CARDIAC: Regular rhythm and rate. S1 and S2 with no significant murmur, rub, or
gallop appreciated. The point of maximal impulse is normal. There is no right ve
ntricular heave.
ABDOMEN: Soft with active bowel sounds. No organomegaly. No audible bruit. Nonte
nder.
EXTREMITIES: Femoral pulses were deferred. Lower extremities revealed trace to 1
+edema at the level of ankles bilaterally.
DIAGNOSTIC DATA: EKG: Electrocardiogram on 11/20/2006 at 1539 showed sinus rhyth
m with left axis deviation, borderline first-degree atrioventricular (AV) block,
sinus arrhythmia. Nonspecific ST-segment flattening seen predominantly in aVL,
but to a lesser extent in lead I. Early R-wave progression also noted. No eviden
ce for resting ischemia or prior infarction. Repeat electrocardiogram on 11/21/2
006 at 0037 essentially unchanged with regard to ST segments except there is per
haps slightly more flattening in lead I. P-wave morphology is slightly different
than that noted on prior tracing consistent with ectopic atrial rhythm. Repeat
electrocardiogram on 11/21/2006 at 1713 shows persistence of ST segment flatteni
ng in lead I, aVL. Persistence of early R-wave progression and left axis deviati
on. Rhythm does appear to be sinus on current tracing.
LABORATORY DATA: White blood cell count 4.7 on admission, hematocrit currently 3

3.2 with platelet count of 243 on admission. INR 1.0 with PTT of 20. Sodium 144
with potassium 3.6, chloride 107, CO2 25, BUN 10 with creatinine of 1.1. Albumin
depressed at 3.3. AST and ALT normal at 19 and 24 respectively, lipase normal a
t 45. Troponins are negative x4 over the course of 14 hours. Urinalysis is sugge
stive of urinary tract infection (UTI) with no blood, positive nitrates, positiv
e leuk esterase, 5 to 10 white blood cells, and many bacteria with no epithelial
cells.
IMPRESSION: Elderly white female status post traumatic left hip fracture with at
ypical chest pain and baseline ST-segment abnormalities nondiagnostic.
RECOMMENDATIONS:
1. Cardiac clearance: The patient with cardiac risk factors including age and fa
mily. Not smoking, hypertensive, dyslipidemic. Does have a sedentary lifestyle,
but it is not morbidly obese. Given the atypical nature of her chest pain and th
e nondiagnostic EKG changes, I feel it is safe to proceed with orthopedic proced
ure without further cardiac evaluation. We would, however, treat with preoperati
ve beta-blockers.
2. We will follow the patient perioperatively with electrocardiogram and troponi
n.
3. We would recommend treatment for presumed urinary tract infection.
FOLLOWUP: The patient will be followed in-house by members of Cardiology Associa
tes and recommendations made as clinically appropriate.
Keywords: cardiovascular / pulmonary, mesothelioma, preoperative cardiac evaluat
ion, atherosclerotic heart disease, st segment flattening, urinary tract infecti
ons, cardiac evaluation, st segment, ondansetron, electrocardiogram, cardiac,