Sample Write Up

Sample Write-up

CV is a 45 y/o woman who presents for evaluation of palpitations and for follow-up on smoking cessation.

 

History

 

Chief Complaint: (1) Palpitations; (2) Smoking cessation follow-up

 

History of Present Illness:

(1)    Palpitations

Patient reports 8 years of occasional palpitations, increasing in frequency to approximately 3x/day over the past month.  She describes the palpitations as the sensation of a rapid heartbeat, enduring seconds before resolving completely without any intervention.  The patient denies any exacerbating factors and remarks that these palpitations occur most commonly at rest.  She states that they occur at random throughout the day, and do not seem to be affected by position.  Patient denies any associated chest pain, syncope, headache, visual changes, dizziness, diaphoresis, abdominal pain or pain.  She does note a strange sensation the she is unable to characterize further in the left side of her neck, as well as the brief sensation of difficulty breathing, during the palpitations.  The patient denies any recent anxiety.  She further denies recent mood changes, hot flashes, or menstrual irregularity.  The patient reports consuming 1 cup of coffee daily and states that she does not consume soda and only drinks decaffeinated tea.  She denies any recent fever, nausea, vomiting, diarrhea, or unintentional weight loss.

 

Past Medical History:

  1. Melena: Reported in 2006. Home fecal occult blood stool tests x3 analyzed 10/23/2006 were negative for blood. Patient informed of results at appointment on 11/20/06. No recurrence of symptoms as of 1/8/07. Patient’s appointment with Dr. Payne on 1/12/07 was cancelled and no new appointment has been scheduled.  Must be followed up at PCP appointment on 4/24/07 if no appointment with GI scheduled before then.
  2. Pruritis of unknown etiology: Reported 10/11/2006. Patient was prescribed Loratidine but reports minimal relief and discontinued the medication. Subsequently was instructed to change moisturizer and purchase humidifier. Patient reports full resolution of symptoms at visit 1/8/07, and does not report any recurrence on 2/5/07. Not addressed at visit on 4/9/07.
  3. Benign Paroxysmal Vertigo: Diagnosed in 2006. Patient prescribed meclizine prn and reports resolution of this problem.
  4. Chronic Headaches: Diagnosed in 2005. No recent episodes as of 4/9/07.
  5. Hyperlipidemia: Diagnosed in 2004. Patient not currently medicated for this condition. Most recent lipid profiles showed total cholesterol of 218, LDL of 172, HDL of 37 and TG of 93. Particularly relevant given report of increase in appetite since initiation of smoking cessation.  Must follow closely, address role of lifestyle changes once smoking cessation is well under control.
  6. Idiopathic Peripheral Neuropathy: Diagnosed in 2005. Patient complained of 3 wks of R hand pain/paresthesias & weakness; ? carpal tunnel vs. ulnar entrapment but w/ weakness. No subsequent episodes have been reported.
Home Medications:
  • Ibuprofen 200mg: 2 tablets q6hrs as needed
  • Carb Cutter Dietary Supplement: contains vitamin c, chromium, absorptive vegetable fiber, banaba leaf extract (lagerstroemia speciosa), gymnema sylvestre leaf and gymnema sylvestre leaf extract (25% gymnemic acids), fenugreek seed extract, super citrimax [60% (-) hydroxycitric acid extract of garcinia cambogia fruit], vanadium (as bmov), guarana seed extract (supplying 60 mg caffeine), Korean ginseng root extract (5% ginsenosides), eleuthero root extract (0.8% eleutherosides), green tea leaf extract (36% total polyphenols)
  • Bisacodyl OTC: prn for constipation

Allergies:

NKDA

Habits:

Tobacco:  Quit smoking 1/15/07.  Previously 1 pack/day since age 18

EtOH: Denies

Recreational drugs: Denies

Family History:

Cancer: daughter diagnosed with Hodgkin’s Lymphoma in 2004

HTN: mother and father

Benign cystic lesion in breast: daughter.

No family history of breast cancer, diabetes, stroke or CAD.

Social History:

Lives in Revere with her two daughters. One daughter completed chemotherapy for Hogdkin’s lymphoma in Oct. 2005. Originally from Brazil, has been in the US for 10 years. Currently works as housecleaner.  States that family serves as her primary source of support.  Her sister is a physician in Brazil.

Review of Systems:

Reports small lesion on left eye at border of iris.  Patient wears glasses but denies any visual impairment associated with this lesion.  All other systems benign.  Denies any recent headaches, chest pain, abdominal pain, melena, nausea, vomiting, fever, or change in mood.

 

Physical Exam

Vitals: T 98.1ºF                BP 116/80            P 60, regular Wt 167

General Appearance: Well-appearing woman who looks her stated age, smiling, sitting in chair, in NAD.

HEENT: NCAT.  PERRL, EOMI. Small 2mm diameter raised clear lesion at nasal border between iris and sclera of left eye.

Thyroid: Small, smooth and symmetric.

Cor: RRR with normal S1 and S2. No S3 or S4. No clicks.  II/VI systolic early crescendo-decrescendo murmur, heard best at the RUSB.  PMI not well palpated.  No carotid bruits.

Lungs: CTAB with good breath sounds. No wheezes, rales or rhonchi appreciated.

Abd: Soft, NT/ND. No organomegaly or palpable masses.  Normal BS in all 4 quadrants.

Neuro: A&O x3. Broadly intact.

Ext: WWP, no C/C/E.

Evaluations

EKG: Normal sinus rhythm at 60bpm. Normal intervals. No evidence of ischemia or arrhythmia.

Assessment and Plan

Problem List:

  1. 1. Palpitations

Patient reports brief, episodic occurrence of palpitations, without positional effect.  The short duration of these palpitations as well as the patient’s denial of any anxiety, depression, or other symptoms typical of a panic attack (such as diaphoresis and a sense of doom) makes a psychiatric explanation less likely. Rather, the patient’s presentation can most likely be explained by benign premature ectopic beats, though 12-lead EKG did not show any evidence of such a process.   Nonetheless, the random, episodic occurrence of these palpitations would be consistent with premature beats, as would the brief duration of the episodes and the patient’s long history of similar episodes starting at a relatively young age.  Ventricular premature contractions could also explain the strange sensation the patient experiences in the left side of her neck.  Other possible considerations in the evaluation of this patient include both cardiac and non-cardiac etiologies.  However, on exam there is no extra heart sound, nor is there evidence of axis shift on EKG, which would suggest a dilated cardiomyopathy.  The murmur which was appreciated is not the murmur typical of mitral valve prolapse (a late systolic murmur heard best at the apex) nor was a systolic ejection click appreciated, making this a less likely diagnosis.  Lack of a shortened PR interval makes WPW syndrome unlikely, while lack of a role for position makes an AVNRT less likely.  Possible non-cardiac etiologies would include thyrotoxicosis, menopause, and medications.  However, a serum assay of TSH which was within normal limits in 12/2006, as well as lack of any associated symptoms or findings on exam, makes hyperthyroidism an unlikely etiology.  The patient reports regular periods and denies any mood changes, night sweats, or hot flashes and thus does not seem to be in menopause.  Regarding drugs, it is possible that the weight loss supplement the patient recently began taking has exacerbated her symptoms, since the initiation of use of this supplement does seem to coincide with the increase in frequency of the palpitations.  However, since the patient reports that she experienced palpitations long before starting this medication, this does not provide a full and satisfactory explanation for the occurrence of the patient’s palpitations.  Furthermore, the medication includes only 60mg caffeine, which is a relatively small dose.  Given all of these considerations, taking into account the reported brevity of the episodes, the lack of concerning findings on EKG, the lack of a cardiac PMH, the young age of the patient and the lack of significant associated symptoms, it seems appropriate to continue to monitor the patient closely but to refrain from any targeted intervention at this time.  The patient should be instructed to stop her weight loss herbal supplement, and to return to clinic if her symptoms worsen or if she begins to experience chest pain, severe shortness of breath, dizziness, or prolonged episodes of palpitations.

Plan:

  1. Reassure the patient that the EKG did not show any concerning findings.
  2. Inform the patient that palpitations are a relatively common complaint and that most palpitations in young otherwise healthy individuals are benign.
  3. Instruct the patient to discontinue use of Carb Cutter Dietary Supplement as this may be contributing to the increased frequency of her symptoms.
  4. Instruct the patient to return to clinic if her symptoms worsen or if she begins to experience chest pain, severe shortness of breath, dizziness, or prolonged episodes of palpitations.

  1. 2. New Heart Murmur

Patient has a II/VI systolic ejection murmur on exam; there is no previous documentation of such a murmur in the patient’s record.  The murmur is quite faint and thus accurate classification requires more detailed evaluation by echocardiogram.  However, on initial assessment by physical exam, the murmur seems to have an early crescendo-decrescendo pattern and is heard best at the RUSB.  The timing, pattern and location of this murmur as appreciated on exam are most consistent with mild aortic stenosis.  Specifically, the murmur seems to be a crescendo-decrescendo pattern, suggesting aortic or pulmonary valve stenosis, rather than a holosystolic murmur (suggesting mitral regurgitation, tricuspid regurgitation or VSD) or a late systolic murmur (which would suggest mitral valve prolapse).  That the decrescendo seems to predominate over the crescendo suggests mild rather than more severe valvular disease, while the location of the murmur indicates aortic rather than pulmonary valve stenosis.  Given the faintness or the murmur, it is possible that the murmur is in fact an early systolic decrescendo murmur indicating mitral regurgitation.  If this murmur did represent new onset mitral regurgitation, acute endocarditis, chordae rupture, ischemia, or acute MI would have to be considered.  However, the patient’s clinical picture is inconsistent with such diagnoses, and an EKG performed at the current visit showed no signs of acute MI or LVH.

Plans:

  1. Explain to patient that heart murmurs are relatively common and there no current cause for alarm.
  2. Schedule patient for echocardiographic evaluation on 4/18/2007
  3. Follow-up on 4/23/07