Cardiology Case Study 5

Cardiology

TAPE 8B, Report 5

CHART NOTE

Patient states she has had 4 to 5 episodes of left substernal burning chest pain which radiates to her left arm and is associated with diaphoresis, nausea, and shortness of breath.  She states the pain usually comes on with exertion, but has come on at rest on several occasions and is usually relieved by 1 to 2 sublingual nitroglycerin.  Patient also reports dyspnea on exertion, occasional orthopnea, and questionable PND.  Reports waking at night coughing several times.  Patient states cough is nonproductive.

PHYSICAL EXAMINATION

HEENT exam was unremarkable.  Neck exam:  Central venous pressure was approximately 9 cm.  There was no adenopathy or bruit.  Cardiovascular exam:  Heart was regular rate and rhythm with a rate of 62 and a positive S4.  No murmur or S3.  On respiratory exam, lungs were clear to auscultation and percussion.

MEDICATIONS

Medications include Tenex 1 mg p.o. q.h.s., Lasix 20 mg p.o. q.d., Clinoril 200 mg p.o. b.i.d., Colace 100 mg p.o. b.i.d., nitroglycerin patch 5 mg topically q.24h., nitroglycerin 0.4 mg sublingually p.r.n. chest pain.

DIAGNOSES

1. Unstable angina.

2. Hypertension.

3. Congestive heart failure.

FOOTNOTE

Line 7.  Alternative:  4-5.

Line 11.  Alternative:  1-2.

Line 17.  Exam was expanded in the heading.

Line 25.  Medication was changed to Medications for subject-verb agreement.

Line 27.  The slang term nitro was translated as nitroglycerin.

Lines 31-33.  The diagnoses were enumerated.