Chapter 10: The Cardiovascular System | Jim Flowers' Chart Note

CHART NOTE

Patient Name: Flowers, Jim
ID Number: 95432
Examination Date: February 18, 20xx

SUBJECTIVE
Jim is a 55-year-old male who presents to the Guardian Urgent Care Clinic after an episode of intense chest pain and tingling and numbness of his left arm that occurred yesterday while driving his daughter to a concert. The pain was relieved by placing a nitroglycerin tablet under his tongue. Because of concerns from both his daughter and wife, he is here today for a follow-up.

OBJECTIVE
BP is 110/84, respirations 20, pulse is 90/min and regular. Temperature normal. His chest X-ray reveals a pacemaker on the left, cardiomegaly, and increased markings suggestive of congestive heart failure. The ECG reveals normal rate and rhythm.

ASSESSMENT
1. Angina pectoris.
2. Cardiomegaly.
3. Possible CHF.

PLAN
Admit patient to County Hospital for cardiac catheterization.