Case -T6-2C PROGRESS NOTE

Essay

Case
-T6-2C PROGRESS NOTE
LOCATION: Inpatient, Hospital
PATIENT: Dennis Deitz
ATTENDING PHYSICIAN: David Barton, MD
SUBJECTIVE: The patient is feeling good. He is not having any more pressure or pain or shortness of breath. His nitroglycerin drip is off, and he is feeling good and would like to go home.
OBJECTIVE: His vitals have been stable. Telemetry has been good. CHEST is clear. No
rales, rhonchi, or wheezing. NECK: Bilateral palpable carotids. HEART: Regular rate and
rhythm with occasional extra beat. EXTREMITIES: No edema.
His EKG (electrocardiogram) shows no acute ischemic changes.
His CPK (creatine phosphokinase) and troponin are normal.
ASSESSMENT:
1. Angina.
2. Coronary artery disease.
3. Hypertension.
4. Hypercholesterolemia.
5. Chronic obstructive pulmonary disease.
PLAN: We will send him home today on the increased dose of the isosorbide to 50 mg (milligram) t.i.d. (three times a day). He should take the morning and afternoon doses a little bit later to see if that will help avoid problems during the night. Atenolol is bumped to 50 mg b.i.d. (twice a day), and we will start him on Plavix 75 mg daily. We will tentatively see him in the clinic next week. He is to take it easy over the weekend and if he has any problems, he should come in to the emergency room over the weekend.
T6-2C:
SERVICE CODE(S): ___________________________________________________
ICD-10-CM DX CODE(S): ______________________________________________