NAME: ___________________________ DATE:___________________

GRADE/SECTION:___________________ SCORE: __________________

ACTIVITY NO: _______ (PERFORMANCE TASKS)

TITLE: MEDICAL TRANSCRIPTION (CARDIOLOGY #6)

ADMISSION NOTE
CHIEF COMPLAINT: The patient is a 53-year-old female who was brought to the emergency room with chief complaint
of chest pain.
HISTORY OF PRESENT ILLNESS: The patient has a history of atherosclerotic coronary artery disease, having undergone
an angioplasty. She had a catheterization done which showed less than 50% blockages of several vessels. Since
that time the patient has had, off and on, a midchest pressure that sometimes she felt was due to esophageal
spasm and sometimes to angina.
On this occasion the patient was restless at night in bed, not under any particular stress or exertion, when she
began to have left substernal chest pressure radiating to her left shoulder, down her left arm, into her left neck,
and into her left jaw. She felt the radiations represented angina. She took 3 nitroglycerin tablets with some
relief, but the chest pressure persisted.
MEDICATIONS: It should be noted that the patient has been off her nitro patch for approximately 2 weeks. She had
been taking her other medications which included Elavil, Moduretic, Mevacor, Persantine, Cardizem 30 mg
q.i.d., Reglan, and probably Zantac.

PHYSICAL EXAMINATION
GENERAL: Physical exam in the ER showed a well-developed, well-nourished 53-year-old female in no acute distress.
Blood pressure 124/86, pulse 84 and regular, respiratory rate 20 and unlabored, temperature 96.5.
HEENT: Within normal limits.
NECK: Supple without jugular venous distention.
CHEST: Clear to auscultation.
HEART: Regular rhythm without murmur, gallop, or rub. Chest wall nontender.
ABDOMEN: Soft, nontender.
Bowel sounds normal.
EXTREMITIES: Without clubbing, cyanosis, or edema.
EMERGENCY ROOM COURSE: An I.V. of D5W TKO was started. An electrocardiogram was obtained which showed
ischemic ST and T wave changes without any infarct changes noted. CBC and total CPK were drawn. CBC
showed a white count of 8.8 with 55 segs, 5 bands, 33 lymphs, 5 monocytes, hemoglobin 13.3, hematocrit 39.8.
CPK 57. Admission chest x-ray was done. The lung fields were without signs of congestive heart failure or
infiltrate. Heart was normal size. Nitro paste 1 inch was placed to the chest.
The patient was given Procardia 10 mg p.o., nasal oxygen at 3 liters by nasal cannula. Morphine sulfate was
given, 2 mg I.V. It was agreed to admit the patient to the CCU with the following diagnosis.
DIAGNOSIS: Unstable angina. Rule out subendocardial myocardial infarction (MI).