Consultation Report Sample:

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Chart Note #1

RE:   Debra Jones
DATE 12/01/10
MR:  240804
DOB: 12/01/65

CHIEF COMPLAINT: Chest pain.

HISTORY OF PRESENT ILLNESS:  This is a 55-year-old white female referred today for chest pain.  She was recently evaluated for a typical chest pain and had exercise stress testing.  She exercised for 9 minutes and 26 seconds and the test was clinically negative.  She continues to have atypical chest pain complaints.  She has no orthopnea, no lower extremity edema, no palpations, or dyspnea on exertion.

PAST MEDICAL HISTORY:  Hypothyroidism.

PAST SURGICAL HISTORY:  Partial hysterectomy, lumbar laminectomy, and benign bony tumor removed from sinus cavity.

SOCIAL HISTORY: She is married and has a 28-year-old son.  She is self-employed.  She makes custom draperies. 

FAMILY HISTORY: Father is deceased from congestive heart failure and mother is still living at age 86 with history of hypertension and CVA.  She has three sisters who are healthy.  She smokes cigarettes one-half pack per day for 25 years.  She quit 10-15 years ago.  She drinks on a social basis, one to two mixed drinks per week.  Caffeine intake, two to three diet Rite Cola’s per day.  Three to five eight-ounce glasses of water per day.  She exercises regularly and walks one to one-and-one-half miles per day, five day a week.  She follows a regular diet with no restrictions.

REVIEW OF SYSTEMS: She has lost 16 pounds since January.  She is positive for easy bruising.  She does experience occasional seasonal allergies symptoms, occasional nocturia, urinary urgency, and hyperkeratosis. 

CURRENT MEDICATIONS: Premarin everyday, Synthroid everyday, and oxybutnin p.r.n.

ALLERGIES:  SULFA DRUGS CAUSE RASH.

PHYSICAL EXAMINATION:  Weight 169 pounds, height 5’8” tall.

VITAL SIGNS:  In the right arm blood pressure 140/80 and in the left arm 130/80.  She has an applicable respiratory rate at 16.
 
GENERAL:  A 56-year-old white female in no acute distress.

SKIN:  Warm and dry. 

PHYSICAL EXAM:
 Unremarkable.

EKG:
 Normal sinus rhythm.

IMPRESSION:
1.  A typical chest pain with negative exercise stress testing on 09/11/02.        
2.  Reform smoker.
3.  Unknown lipid status.
4.  Hypertension.

DISCUSSION:  At this time, chest pain appears to be caustic chondritis, will treat with Motrin.  Check fasting lipids.  I will see the patient back in the office in four weeks and reevaluate blood pressure readings at that time, as to whether or not medical therapy will be necessary.