Counselling Skills
CARDIOLOGY/HEMATOLOGY REPORT #6 Jonathan Vicors
OFFICE HISTORY AND PHYSICAL EXAMINATION
He is a 47-year-old male who states that he has had a 7-year history of palpitations which he described as skipped or fast beats. He states that the trigger is unclear. They can either last a few seconds several days, but he states also that he has had no rapid beating for sustaining durations. He states that he also can get several episodes of per month. He states by full, he had an echocardiogram done 7 years ago when these symptoms presented themselves. However, it was "normal." He also states that these palpitations are not aggravated by exercise or weight lifting.
PAST MEDICAL HISTORY
Positive for borderline hypertension for the last 7 years. He denies history of stroke, coronary artery disease, myocardial infarction, diabetes or cancer.
Hospitalizations include one at age 10 for suspected rheumatic fever.
FAMILY HISTORY
Father is living, age 74. He does have Alzheimer's but otherwise in good health. Mother is living in her 70s also. She is a breast cancer survivor.
SOCIAL HISTORY
Is a nonsmoker. He also denies any type of caffeine use. He admits to rare alcohol use. He denies any type of illicit drug use. He is married. He has two children who are living and well, and he exercises on a daily basis, either with weight traing or cardio workout. He is employed full time.
MEDICATIONS
Current medications include vitamins, that being in a form of a multivitamin, vitamin C which he takes on a daily basis, and fish oil when he remembers.
ALLERGIES
No known drug allergies.
REVIEW OF SYSTEMS
Constitutional: Negative for fever or viral illness. He admits to fatigue primarily after his episodes.
Eyes: He has no visual changes or field deficits. However, he does wear glasses for vision correction.
ENT: Negative.
Respiratory: Negative.
Cardiovascular: Negative.
GI: Negative.
GU: Negative.
Musk skeletal: Negative.
Integementary: Negative.
CARDIOLOGY/HEMATOLOGY REPORT #6
OFFICE HISTORY AND PHYSICAL EXAMINATION
He is a 47-year-old male who states that he has had a 7-year history of palpitations which he described as skipped or fast beats. He states that the trigger is unclear. They can either last a few seconds several days, but he states also that he has had no rapid beating for sustaining durations. He states that he also can get several episodes of per month. He states by full, he had an echocardiogram done 7 years ago when these symptoms presented themselves. However, it was "normal." He also states that these palpitations are not aggravated by exercise or weight lifting.
PAST MEDICAL HISTORY
Positive for borderline hypertension for the last 7 years. He denies history of stroke, coronary artery disease, myocardial infarction, diabetes or cancer.
Hospitalizations include one at age 10 for suspected rheumatic fever.
FAMILY HISTORY
Father is living, age 74. He does have Alzheimer's but otherwise in good health. Mother is living in her 70s also. She is a breast cancer survivor.
SOCIAL HISTORY
Is a nonsmoker. He also denies any type of caffeine use. He admits to rare alcohol use. He denies any type of illicit drug use. He is married. He has two children who are living and well, and he exercises on a daily basis, either with weight traing or cardio workout. He is employed full time.
MEDICATIONS
Current medications include vitamins, that being in a form of a multivitamin, vitamin C which he takes on a daily basis, and fish oil when he remembers.
ALLERGIES
No known drug allergies.
REVIEW OF SYSTEMS
Constitutional: Negative for fever or viral illness. He admits to fatigue primarily after his episodes.
Eyes: He has no visual changes or field deficits. However, he does wear glasses for vision correction.
ENT: Negative.
Respiratory: Negative.
Cardiovascular: Negative.
GI: Negative.
GU: Negative.
Musk skeletal: Negative.
Integementary: Negative.
CARDIOLOGY/HEMATOLOGY REPORT #6