Module 4
Chief complaint
Hard to breathe
Vendor Order 1704PC04 added on 04/06/17 Other
Imaging Order 1704PBWM added on 04/06/17 Other
PATIENT Steve Nguyen DOB 03/15/1943 AGE 74 yrs SEX Male PRN SS892268
FACILITY Northstar Physicians Center T (999) 999-9999 1234 Sunshine Way 100 Minneapolis, MN 99999
ENCOUNTER
NOTE TYPE SOAP Note SEEN BY Nazir Ashaad DATE 04/03/2017 AGE AT DOS
74 yrs
Not signed
Orders
LAB ORDERS
407 - Cholesterol (Total)
2089-1 - Cholesterol in LDL
445 - HDL Cholesterol in Serum or Plasma
134 - Triglycerides
249 - Glucose (Fasting)
48 - HbA1c blood
IMAGING ORDERS
1276 - Aorta CT angiogram W contrast IV
5091 - Echocardiogram with doppler color flow
4724 - Coronary arteries CT angiogram and 3D reconstruction W contrast IV
Free cloud based EHR
Encounter - Office Visit Date of service: 04/03/17 Patient: Stev... https://static.practicefusion.com/apps/ehr/?c=1385407302#/PF/...
1 of 1 4/6/17, 4:23 PM
Northstar Laboratory
3456 Sunshine Way #300
Minneapolis, MN 99999
Phone: (555) 555-5555
Patient: Steve Nguyen
DOB: 03/15/1943
Lab Results
Component Your Value Standard Range Units
Total Cholesterol 268 0-200 mg/dL
HDL 36 30-75 mg/dL
LDL 162 0-100 mg/dL
Triglyceride 172 0-150 mg/dL
Component Your Value Standard Range Units
Blood Glucose (fasting) 221 80-100 mg/dL
Hemoglobin A1c 7.5 4.0-5.9 %
Comments Cholesterol panel shows increased values for total cholesterol, LDL, and triglyceride tests. Continue current medication and refer to nutritional counseling received from dietician on your last office visit. Re-evaluation of these cholesterol levels is recommended in 3 weeks. Blood glucose and A1c levels remain at diabetic levels. Consult with physician regarding your current diabetes care plan. Medication alterations may be necessary.
Interpretation by: Pamela Yost, MD
Northstar Imaging Center
2345 Sunshine Way #200
Minneapolis, MN 99999
Phone: (555) 555-5555
Patient: Steve Nguyen
DOB: 03/15/1943
Indication Coronary CTA to evaluate the cause of chest pain or dyspnea. Evaluate need for bypass surgery or intracoronary artery stent placement. Clinical History Chronic HTN with acute angina. Personal and family history of CHD. Procedure
1. Selective coronary angiography with contrast was performed using CT scanner. Axial images were obtained from the level of the subclavian artery/aortic arch/ascending aorta through to the diaphragm at 0.6 collimation mm section thickness.
2. 65 ml of intravenous contrast was injected via a right/left antecubital intravenous catheter at 4 ml/sec with 50 ml of saline infused immediately afterward.
3. One dose of 0.4 mg sublingual/sublingual nitroglycerin was given approximately 5 min prior to the CTA. The heart rhythm was regular without frequent atrial or ventricular premature beats.
Findings HEMODYNAMICS: The aortic pressure was 117/61 with a mean pressure of 83. The left ventricular pressure was 119/9 to 19 with left ventricular end-diastolic pressure of 17 to 19 mmHg. The pullback across the aortic valve reveals zero gradient. ANATOMY: The left coronary artery main showed minimal calcification as well as the proximal LAD. No stenosis in the left main seen, the left main bifurcates in to the LAD and left circumflex. The LAD was a large and a long vessel that wraps around the apex showed no focal stenosis. Atheromatous plaques present. The LAD gave off two early diagonal branches. The second was the largest of the two and showed moderate lumen irregularities, and moderate 30 to 40% narrowing. The RCA was a small non-dominant system with no focal stenosis and supplying the RV marginal. No mitral regurgitation identified. Impression 1. Moderate stenosis of coronary arteries including left anterior descending coronary artery. 2. Right coronary artery is free of atheromatous plaque. 3. Moderate Disease (30 - 40% occlusion of left coronary artery) 4. Recommendation is aggressive medical management consisting of aggressive lifestyle modifications and statin therapy.