Module 3 Mock Medical Record Ch. 9.docx - Office Visit Note...

Office Visit Note
Patient Name: Henry Wilson
ID No: 390086-241
Date of Exam: 3-20-2013
Chief Complaint: 58-year-old man complains of midsternal chest pain radiating to both shoulders.
History: Patient has a unremarkable history.
Family History: His father died of an MI at age 81. Mother is age 82 with a history of HTN and
hypercholesterolemia.
Physical Exam: BP 158/96, P 100, height 6’0”, weight 224 pounds. Neck: no carotid bruits or JVD. Lungs
clear to auscultation bilaterally. Extremities: no clubbing, clots, cyanosis, or edema.
Diagnostic Studies: EKG is normal. Echocardiogram is normal. Cardiac enzymes are WNL. Cholesterol is
250. Thallium stress test showed chest pain with exertion. Cardiac catheterization showed blockage in
three main coronary arteries.
Diagnosis: 1. Hypercholesterolemia; 2. CAD; 3. Angina pectoris
Plan: Schedule patient for CABG in the A.M. Need stat lipids, CBC, chemistries, and CXR.