A medical professional received the following consultation report. However, after looking over the following report, she noticed there are four glaring errors that need to be corrected. Some words are misspelled; other words are used incorrectly to describe the patient’s problem. Working with someone else, identify the errors in this report. Correct all of the errors so that the medical professional can better serve the patient’s needs.
Consultation Report
Patient Name: John Doe
Patient Age: 55
Date of Consultation: January 15, 2022
Chief Complaint:
The patient presents today with complains of cest pain and shorness of breast.
History of Present Illness:
Mr. Doe is a 55-year-old male who complains of cest pain, shorness of breast, and fatigue. He reports that the cest pain started approximately two months ago and is described as a burning sensation in the left side of his chest. The patient states that the shorness of breast and fatigue have been worsening over the past few weeks. He denies any associated symptoms such as cough, fever, or weight loss. The pain is exacerbated by physical exertion and relieved by rest. Mr. Doe has no previous history of similar symptoms.
Review of Systems:
The patient reports occasional night swets and a red rash on his chest. He denies any other systemic complaints. His past medical history is significant for hypertension, for which he takes metoprolol.
Physical Examination:
Vital signs reveal a blood pressure of 140/90 mmHg, temperature of 98.6°F (37°C), heart rate of 80 beats per minute, and respiratory rate of 16 breaths per minute. On auscultation, the heart rate is regular with no murmurs, rubs, or gallops. Occasionally, I noticed the patient experiencing palpitations. Lung fields are clear to auscultation bilaterally, without any wheezes, rales, or rhonchi. There is a red, scaly rash on the patient’s chest.
Assessment and Plan:
The patient is a 55-year-old male with complains of cest pain, shorness of breast, and fatigue. Based on the patient’s history and physical examination, the differential diagnosis includes angina pectoris, myocardial infarction, and pericarditis. Further investigations are warranted to rule out any underlying cardiac pathology. An ECG, cardiac enzymes, and stress test should be considered. Additionally, an echocardiogram may be necessary to evaluate cardiac structure and function.
To address the patient’s symptoms, sublingual nitroglycerin can provide immediate relief of angina symptoms. If the patient continues to experience symptoms, long-acting nitrates such as isosorbide mononitrate can be prescribed. Beta-blockers like metoprolol can also be initiated to reduce the frequency and severity of angina episodes.
The patient should be advised to make lifestyle modifications, including a heart-healthy diet, regular exercise, smoking cessation, and stress reduction. If the patient’s symptoms persist despite medical therapy, a cardiac catheterization may be needed to evaluate for any significant coronary artery disease.
The patient will be scheduled for an ECG, cardiac enzymes, and stress test. Follow-up will be provided in one week to discuss the results and make further management decisions based on the findings.