Scribe BC - CST New

Scribe BC - CST New Dear Dr. Emily Carter, Thank you for asking us to see Oliver Smith for cardiac assessment. CARDIAC DIAGNOSES: Oliver Smith has been diagnosed with a small atrial septal defect (ASD), which was detected during a routine check-up. The ASD is hemodynamically insignificant, with no evidence of right ventricular volume overload or pulmonary hypertension. CARDIAC SURGICAL AND INTERVENTIONAL HISTORY: Oliver has no history of cardiac surgical or interventional procedures. NON CARDIAC CO MORBIDITIES: Oliver has no non-cardiac co-morbidities. MEDICATIONS: * None ALLERGIES: * No known allergies. PAST MEDICAL HISTORY: Oliver's past medical history is unremarkable. He was born full-term with no complications. He has had all routine childhood vaccinations. FAMILY HISTORY: Father has a history of hypertension. Mother has no known cardiac conditions. No family history of sudden cardiac death, pacemakers, or defibrillators. Family history is unremarkable for congenital cardiac defects, sudden cardiac deaths, pacemakers and defibrillators in the younger population. SOCIAL HISTORY: Oliver lives at home with his parents. He is a happy and active child. CLINICAL PRESENTATION: I saw Oliver, who is 6 years old with a small atrial septal defect (ASD) on 1 November 2024. Since the last assessment, Oliver has remained well with no history of breathlessness with activity or feeding. The baby is breastfed and finishes within 10 minutes. There is a history of no increased work of breathing with feeds. The weight gain has been appropriate for his age. There is no history of colour change with activity. Oliver is at day care doing all sorts of activities without experiencing chest pain, palpitations or fainting. Review of systems did not reveal any major issues relevant to cardiac status. His immunizations are up to date. He to early to have any immunizations. PHYSICAL EXAMINATION: * Heart Rate: 80 bpm * Blood Pressure: 100/60 mmHg * Respiratory Rate: 20 breaths/min * Temperature: 37°C On examination, Oliver appeared comfortable and pink in colour. There were no obvious dysmorphic features seen. Precordial assessment revealed no evidence of any surgical incisions. The precordium was quiet. There was no evidence of any heaves or thrills. Auscultation revealed normal first and second heart sounds. I did not appreciate any murmurs or clicks. There was presence of grade 2/6 systolic murmur at the left sternal border. There was a presence of no additional findings of grade 0/6 at no additional location. The abdomen was soft with no evidence of hepatomegaly. The femoral pulses were well felt. The capillary refill was less than 2-3 seconds both centrally and peripherally. There is no evidence of subcostal and intercostal recession. Air entry was equal to both lung fields. There were no wheezing sounds heard. INVESTIGATIONS: EKG: A 12-lead EKG revealed sinus rhythm with a heart rate of 80 BPM. The QRS progression was normal. All the measured intervals were within normal limits. The QTc interval was 400 milliseconds. ECHOCARDIOGRAM: Echocardiogram confirmed the presence of a small ASD with a shunt ratio of 1.2:1. Right ventricular size and function were normal. Pulmonary artery pressure was within normal limits. IMPRESSION & PLAN: Oliver's cardiac status is stable, with a small, hemodynamically insignificant ASD. A further follow-up cardiac assessment in 12 months is recommended. Activity recommendation: Oliver can continue with all normal activities. Antibiotic prophylaxis requirement with dental work: Oliver does not need any antibiotic prophylaxis for dental work up or any other procedure causing bacteremia but maintaining good oral hygiene and regular dental check up is necessary. **_"The patient provided verbal consent to use the AI scribe during this visit, understanding its purpose, potential benefits, and as well as any associated privacy and security risks."_**