Sample Report: History and Physical: Cardiac Tamponade
CHIEF COMPLAINT: Chest pain with diaphoresis.
HISTORY OF PRESENT ILLNESS: The patient is an 82-year-old white female who developed chest pain earlier today. She became diaphoretic but experienced no syncope.
PAST MEDICAL HISTORY: A dual-chamber permanent pacemaker was placed approximately a month ago because of paroxysmal atrial fibrillation and sinus node dysfunction. The patient has been in remarkably good health all her life and until her recent cardiac problems, had never been hospitalized.
MEDICATIONS: The patient is currently taking amiodarone and warfarin.
ALLERGIES: There are no known medication allergies.
FAMILY HISTORY: The patient has never been married. She is the last survivor of 8 siblings. She is a retired teacher.
PHYSICAL EXAMINATION: GENERAL: The patient is sitting up in bed. She is in obvious respiratory distress, pale, and diaphoretic. VITAL SIGNS: Blood pressure is 60 mmHg systolic; diastolic pressure is not measurable. Temperature is 99, pulse is 110, respirations 24. HEAD AND NECK: There is raised jugular venous pressure. No other abnormalities are noted. LUNGS: The lungs are clear. HEART: The heart sounds are muffled. ABDOMEN: Not examined. GENITALIA: Not examined.
EXTREMITIES: There is no peripheral edema.
ASSESSMENT: Electrocardiogram on admission revealed sinus tachycardia and old left bundle branch block with no new changes. There were no abnormal findings on pacemaker interrogation. Emergency echocardiogram reveals cardiac tamponade with right atrial systolic inversion and right ventricular systolic collapse.
PLAN: She will be admitted for emergent thoracotomy and monitoring.