Cardiology Service Note
1. X-ray shows pleural effusion
2. Current medications patient taking: Tylenol, insulin
3. Patient Quote: “I can’t lie down to sleep and my chest feels heavy.”
4. Visible signs: Bilateral lower extremities edema,
breathing appears labored
5. Reason for patient's visit: dyspnea and angina for the last 3 days
6. Electrocardiogram shows mild bradycardia
7. Diagnosis: congestive heart failure, poorly controlled diabetes
8. Tests needed: repeat electrocardiogram, CBC
9. Previously diagnosed with diabetes, rheumatoid arthritis
10. Needs referral to endocrinologist
11. Drugs needed: antiarrhythmic, diuretic, and anticoagulant
12. Patient is 78 years old, female
13. Blood pressure: 130/85, pulse: 65; respirations: 14, temperature: 99.1
14. Family history of breast cancer, heart disease, and stroke
15. Sputum sample needed
16. Current complaints: polyuria, polydipsia, dyspnea, angina
17. Echocardiogram showed cardiomegaly
18. Blood sugar levels elevated
19. Weight: 175 lbs