PAST MEDICAL HISTORY: 

Mitral valve prolapse, atypical chest pain and palpitations.

PAST SURGICAL HISTORY:

Hysterectomy, bladder suspension and appendectomy. 

CURRENT MEDICATIONS:

Atenolol 50 mg a day, verapamil 120 mg a day, one baby aspirin a day and Celexa 40 mg a day.

SOCIAL HISTORY:

Positive for tobacco abuse.

FAMILY HISTORY:

Positive for coronary artery disease.

REVIEW OF SYSTEMS:

She denies fevers, chest pain, night sweats, strokes, cough or diabetes mellitus.  Otherwise, ten-point review of systems is negative.

PHYSICAL EXAMINATION:

She is in no acute distress.  Her neck veins are not distended.  Respiratory exam is clear to auscultation.  Cardiac exam reveals a normal rate and rhythm.  Normal S1 and S2.  No murmur, rubs, clicks are clearly auscultated.  Abdomen is soft and nontender to palpation without organomegaly.  Extremities reveal no clubbing, cyanosis or edema.  GU exam reveals no costovertebral angle tenderness.  Her neurological examination is nonfocal.

ELECTROCARDIOGRAM:

Sinus rhythm without significant ST segment abnormalities.

IMPRESSION:

1.  Chest pain with atypical features: As it is not associated with exertion and has radiation over to her body. No clear explanation has been found for this.  Whether this represents any arrhythmia, a cardiac or non-cardiac problem is unclear.

2.  Palpitations: The patient had an evaluation for this in the past with limited Holter, which was not helpful.
3.  Mitral valve prolapse: No clear evidence of this has been made, although it has been documented under previous echo.  No murmur was noted on the examination.

RECOMMENDATIONS:

The patient presents with symptoms of palpitations, atypical chest pain and preserved exercise tolerance.  No good explanation of her chest pain has been found.  I have recommended getting an event recorder to try to calibrate her symptoms to arrhythmia or ST segment changes.  In addition, I have checked a basic metabolic factor such as a C-reactive protein, lipid, CBC, TSH, UA, and BMP.  I plan to see her in followup after six weeks.  If she has no clear explanation for this, depending on what her event recorder shows possible further evaluation may include consideration of an empiric trial for reflux, evaluation of her gallbladder in view of negative possible cardiac catheterizations to rule out coronary artery disease certainty.