DATE OF CONSULTATION: MM/DD/YYYY
REFERRING PHYSICIAN: John Doe, MD
REASON FOR CONSULTATION: Junctional rhythm.
HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old female with a history of skeletal malocclusion, status post orthodontic surgery, postoperative day #1. The patient is asymptomatic. Dr. John Doe called for abnormal rhythm with inverted T waves on telemetry. The patient denies any chest pain, shortness of breath, palpitations. She has never had a syncopal episode. Vital signs are stable.
PAST MEDICAL HISTORY: Orthodontic surgery, postoperative day #1, secondary to skeletal malocclusion. The patient has had her wisdom teeth removed in the past.
MEDICATIONS: None.
ALLERGIES: None.
SOCIAL HISTORY: The patient lives alone. She denies tobacco, alcohol or drugs.
FAMILY HISTORY: Grandmother had coronary artery disease and bypass surgery in her 50s.
RISK FACTORS: Family history.
PHYSICAL EXAMINATION:
GENERAL: The patient is alert and oriented x3. The patient is a (XX)-year-old Hispanic female in no acute distress.
VITAL SIGNS: Blood pressure 108/58, heart rate 94, respirations 18, temperature 98.2 degrees, and saturations are 97%.
HEENT: Incisions noted from orthodontic surgery. Dressings intact. Eyes packs are placed.
NECK: No JVP, carotid bruits or thyromegaly.
HEART: S1 and S2. No murmurs, rubs, or gallops.
LUNGS: Clear to auscultation and percussion bilaterally.
ABDOMEN: Soft and nontender.
EXTREMITIES: No edema.
DIAGNOSTIC DATA: EKG: Normal sinus rhythm, 90 beats per minute. No abnormalities noted. Telemetry: Sinus rhythm with ectopic atrial rhythm and underlying rhythm is sinus rhythm.
LABORATORY DATA: WBC is 9.2, hemoglobin 14.2, hematocrit 41.8, platelets 286,000. Pregnancy test is negative.
IMPRESSION:
1. Ectopic atrial rhythm, asymptomatic, and low risk for cardiac events.
2. Status post orthodontic surgery for skeletal malocclusion, postoperative day #1.
PLAN: Monitor on telemetry. Rhythm was reviewed with EP specialist, Dr. Jane Doe, in our group, recommended echocardiogram. If this is normal, the patient can be discharged and follow up as an outpatient.
