T6-2C PROGRESS NOTE SUBJECTIVE: the Patient Is Feeling Good. He Is

question 1

Essay

T6-2C PROGRESS NOTE
SUBJECTIVE: The patient is feeling good. He is not having any more pressure or pain or shortness of breath. His nitroglycerin drip is off, and he is feeling good and would like to go home.
OBJECTIVE: His vitals have been stable. Telemetry has been good. CHEST is clear. No rales, rhonchi, or wheezing. NECK: Bilateral palpable carotids. HEART: Regular rate and rhythm with occasional extra beat. EXTREMITIES: No edema.
His EKG (electrocardiogram) shows no acute ischemic changes.
His CPK (creatine phosphokinase) and troponin are normal.
ASSESSMENT:
1. Angina.
2. Coronary artery disease.
3. Hypertension.
4. Hypercholesterolemia.
5. Chronic obstructive pulmonary disease.
PLAN: We will send him home today on the increased dose of the isosorbide to 50 mg (milligram) t.i.d. (three times a day). He should take the morning and afternoon doses a little bit later to see if that will help avoid problems during the night. Atenolol is bumped to 50 mg b.i.d. (twice a day), and we will start him on Plavix 75 mg daily. We will tentatively see him in the clinic next week. He is to take it easy over the weekend and if he has any problems, he should come in to the emergency room over the weekend.
T6-2C:
SERVICE CODE(S): ___________________________________________________
ICD-10-CM DX CODE(S): ______________________________________________

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Definitions:

New Deal

A collection of initiatives, including programs, public work projects, financial reforms, and regulations, that were implemented by President Franklin D. Roosevelt in the United States throughout the 1930s as a reaction to the Great Depression.

Social Security

A governmental program designed to provide financial assistance to elderly, disabled, and survivors through retirement benefits, disability insurance, and other means.

Americans Working

The portion of the U.S. population engaged in employment, reflecting the labor force's health and economic activity levels.

Depression

An extended period of significant economic downturn, characterized by a substantial decrease in economic activity, high unemployment, and deflation.