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2. Using appropriate terminology and abbreviations, make a charting entry for Mr. Cochrans angina pectoris diagnosis by usin
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Answer #1

Angina pectoris

Subjective

  • Pain on chest
  • Breathing difficulty
  • Heartburn
  • Nause
  • Palpitations
  • Dizziness
  • Inability to do activity
  • Relieves after a short while or after rest

Objective

  • Tachycardia
  • Dyspnea
  • Anxiety
  • Perspiration

Assessment

  • Vitals:Elevated blood pressure, heart rate rate
  • Electrocardiograph
  • Cardiac markers (Trop T ,Trop I,CPK MB)
  • Chest X ray
  • Coronary angiography

Plan

  • To start on medication like anti angina, blood thinners ,lipid lowering drugs and antihypertensive drugs
  • Prepare the patient for angioplasty if there is a block

Education

  • Educate on lifestyle modification
  • Regular exercise
  • Cardiac or a Meditarean diet which is more effective to control cardiovascular diseases
  • Create awareness on any side effects and to report immediately

Response

  • The patient will have no chest pain and will lead a normal quality life.
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