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Rapid Heart Rate Emergency Room Sample Report

DATE OF ADMISSION:  MM/DD/YYYY

CHIEF COMPLAINT:
Rapid heart rate.

HISTORY OF PRESENT ILLNESS:
This is a (XX)-year-old male who presents to the emergency department by squad. Apparently, just prior to arrival, he left work, was in his car, when his heart started racing. He states that he did have some chest tightness, 4/10 in intensity. No shortness of breath, nausea or vomiting. The patient states he had an ablation done in the past. He states he forgot to take his digoxin the last few days. He has never had a stress test.

PAST MEDICAL HISTORY:
1.  SVT.
2.  Hypertension.

MEDICATIONS:
1.  Digoxin.
2.  Toprol.

ALLERGIES:
None.

SOCIAL HISTORY:
The patient denies tobacco use. Occasionally, he drinks alcohol.

FAMILY HISTORY:
The patient's father has had a history of hypertension, and the patient's grandmother has had a history of coronary artery disease.

REVIEW OF SYSTEMS:
All systems are reviewed and otherwise negative.

PHYSICAL EXAMINATION:
VITAL SIGNS:  BP 152/108, temperature 98.4, pulse 190, respirations 18, O2 sat 98% on room air.
GENERAL:  The patient is a well-developed male who appears anxious.
HEENT:  Moist mucous membranes.
NECK:  Supple, no JVD.
HEART:  Tachycardic, otherwise regular rhythm, S1, S2.
LUNGS:  Clear to auscultation bilaterally.
ABDOMEN:  Nontender, obese.
EXTREMITIES:  No clubbing, cyanosis or edema.

LAB RESULTS:
Chest x-ray shows no acute findings by my reading. EKG shows a supraventricular tachycardia with a rate of 190. No acute findings on reading. Troponin normal.

WBC 14.8, otherwise normal CBC. Digoxin level 0.5. Chem-7 is normal, except for a glucose of 118.

EMERGENCY DEPARTMENT COURSE:
The patient was seen and examined. An IV was established in his left antecubital region. He was found to be in supraventricular tachycardia. He was given 6 mg of adenosine without conversion. He was given a repeat dose of 12 mg without conversion. He was bolused with Cardizem 20 mg and started on a drip at 15 mg an hour. He was rebolused with 25 mg of Cardizem. His rate began to come down into the 150s range and then he converted into a sinus rhythm. His old charts were reviewed. We did discuss the patient with Dr. John Doe, who is covering for his cardiology group, and the patient was discharged in good condition.

MEDICAL DECISION MAKING:
The patient is a (XX)-year-old male with a supraventricular tachycardia. We will discharge him to home. He is to take his medications as directed. He is to follow up with his cardiologist and return if symptoms worsen.

DISPOSITION:
Home.

DIAGNOSIS:
Acute supraventricular tachycardia, resolved.

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