Chapter 10: The Cardiovascular System | Samuel Gibson's Chart Note

CHART NOTE

Patient Name: Gibson, Samuel
ID Number: 25448
Examination Date: March 1, 2014

SUBJECTIVE
Mr. Gibson is an obese 64-year-old male who is slightly dyspneic (pertaining to difficulty breathing) with a history of hypertension who yesterday experienced chest discomfort. The patient describes persistent pain across the upper chest with associated severe dyspnea. This occurred while walking his dog. Chest discomfort resolved after resting on a bench. The patient awoke today to chest pain and seeks advice.

OBJECTIVE
Blood pressure is 144/91 with a pulse of 80. Respiratory rate is 16/min. Heart is regular in rate and rhythm. Cardiac risk factors include hypertension, obesity, and a positive family history of CAD. Electrocardiogram is normal.

ASSESSMENT
1. Unstable angina pectoris
2. Hypertension

PLAN
Admit patient to County Hospital to exclude myocardial infarction and to initiate therapy with beta blockers (drugs used to reduce hypertension), aspirin, and heparin (blood thinner). The patient will also undergo cardiac catheterization.