Chapter 10: The Cardiovascular System | Richard Thomas's Chart Note

CHART NOTE

Patient Name: Thomas, Richard
ID Number: 61842
Examination Date: July 19, 20xx

SUBJECTIVE
This 71-year-old male has a history of multiple episodes of epistaxis (nosebleeds). No history of nose trauma. Hemorrhage comes on spontaneously, usually at night or in the early morning. He may go a couple of months with one and then gets one every day for a few weeks. They start at rest and occasionally with exertion. He has been able to stop the bleeding by applying direct pressure to the nose. He has no other bleeding problems. He is currently taking antihypertensive (pertaining to preventing or controlling high blood pressure) medications.

OBJECTIVE
Blood pressure is 176/80; pulse 80. There is no active bleeding at this time. A small, dried blood clot is noted in the left nostril, which may be the bleeding site.

ASSESSMENT
1. Hypertension
2. Recurrent epistaxis

PLAN
Patient was given Procardia XL® sublingually (pertaining to under the tongue), with blood pressure dropping to 140/75. Vaseline® jelly was applied to the left nostril anteriorly. Patient was instructed in treatment of nosebleeds if they recur. Patient instructed to take Procardia XL once daily. Follow up for blood pressure check in 2 weeks.