Cardiology Case Study 4


Cardiology

TAPE 8B, Report 4

CHART NOTE

The patient has had 2 myocardial infarctions and is essentially a cardiac cripple.  His ejection fraction is quite low.

Blood pressure 136/66, pulse 80, respirations 24, temperature 97.6.  Heart:  Regular sinus rhythm.  Abdomen normal.  No edema.  Bilateral rales are present.

Laboratory work showed the ECG with sinus tachycardia, 15.7 white count, and hemoglobin 17.8.

The patient was given aminophylline, Lanoxin 0.25, Lasix 40 mg, Cardizem.  To be seen in the office in 1 week.

FOOTNOTE
Line 10.  Respirations are preferably written in plural.
Line 17.  A zero was placed before the decimal point for clarity.

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