DATE OF CONSULTATION: MM/DD/YYYY
REFERRING PHYSICIAN: John Doe, MD
REASON FOR CONSULTATION: Near syncope.
HISTORY OF PRESENT ILLNESS: This is a (XX)-year-old African-American female. She was in her usual state of health, according to the patient. She was feeling dizzy for the last four to five days. She states she ate quite a bit, and after that, she states the next morning, she was not feeling well and then she states she had a little pain in her stomach area. She took some orange juice. It got better. The patient denies any chest pain per se. She denies any nausea, vomiting or diaphoresis. Denies any syncopal episode. Does give a history of palpitation. No history of PND or orthopnea. No history of CHF. No history of MI. Denies any other complaint. The patient is physically active. She states she started to exercise. She does treadmill about 20 minutes without any symptoms of exertional angina.
PAST MEDICAL HISTORY: Significant for arrhythmias, acidity. She states she took Corgard for about nine years and then she stopped for the past five years.
FAMILY HISTORY: Negative for premature coronary artery disease.
SOCIAL HISTORY: The patient has no history of smoking. No history of alcohol abuse. No history of drug abuse. She is married and has two children.
REVIEW OF SYSTEMS: No history of fever or chills. No history of COPD or asthma. No history of constipation, diarrhea or rectal bleeding. No history of arthritis. No history of stroke. Other review of systems are negative.
PHYSICAL EXAMINATION:
GENERAL: Mild overweight African-American female, sitting comfortably in chair, not in any distress.
VITAL SIGNS: Blood pressure is 134/74, pulse is 76, respirations 20.
HEENT: Head is atraumatic and normocephalic. Eyes: Pupils equal, round, reactive to light and accommodation. Extraocular movements are intact. Conjunctivae pink. Sclerae nonicteric. Facial skin is warm, moist, intact. No rashes. ENT: No inflammation. No discharge.
NECK: Supple. No JVD. No bruit. No thyromegaly.
CHEST: Clear bilaterally.
HEART: S1, S2, regular. No murmur, no gallop, no rub. PMI at fifth intercostal space.
ABDOMEN: Soft and benign. Positive bowel sounds. No organomegaly. No rebound. No guarding.
EXTREMITIES: Normal pulses. No edema. No cyanosis.
NEUROLOGIC: Alert and oriented x3. No gross focal deficit.
DIAGNOSTIC TESTS: EKG: Normal sinus rhythm. Sinus tachycardia, heart rate is 110 beats per minute. No acute ischemic changes noted. No ST elevation noted. Nonspecific T-wave abnormality noted.
IMPRESSION:
1. Near syncope.
2. History of supraventricular tachycardia.
RECOMMENDATIONS: We will recommend starting the patient on beta blocker. The patient might be having an episode of near syncope secondary to her supraventricular tachycardia. We will recommend 2-D echocardiogram to rule out any valvular heart disease. The patient, on examination, does not have any significant murmur. We told the patient to ambulate and see how she feels. Encouraged the patient to increase p.o. fluids. Further plan of care will be dictated by the patient’s response to the above-mentioned treatment.
Thank you for the consultation, Dr. Doe. If you have any questions, please feel free to contact us.
