Outpatient Clinic Attendance – Cardiology Department

Organisation: Lancashire Hospital Trust

DATE OF ARRIVAL:                                                                           05-May-2006 14:00                             
DATE OF LEAVING DEPARTMENT:                                              05-May-2006 16:20

Date Document Sent: 05-May-06 16:45

Hospital: St. Elsewhere’s Hospital
Senior Physician: Dr. Harry Pollock

Primary Recipients:
PSIS, GP (Dr. Leister Farnham)

Reason for Referral[ection 1]

Crushing central chest pain[a] on exertion. Lasts for 5 minutes relived immediately by GTN. 6 occurrences in the last 2 weeks.

Relevant History[section 2]

Previously fit and well. Smoker average of 15 per day[b] since 1956.
Father died of heart attack at age 52 (in 1949).

Findings on Examination[section 3]

Blood Pressure 140/85[c]

Investigation Results[section 4]

Investigation
Results
Standard Chest X – ray[d]
Normal
Standard ECG[e]
Normal
Exercise ECG[f]
Abnormal - significant ischaemic changes in antero-lateral leads.
Full Blood Count[g]
  Haemoglobin level[h]
13.2g/dl
  White Cell Count[i]
4.5x109/l
  Platelets[j]
254x109/l
Urea and Electrolytes[k]
  Sodium[l]
133mmol/l
  Potassium[m]
4.0mmol/l
  Bicarbonate[n]
28mmol/l
  Urea[o]
3mmol/l
  Creatinine[p]
50micromol/l
  Chloride[q]
101mmol/l

Diagnosis[section 5]

Exertional angina[r]


Medications[section 6]


Item
Dose
Supplied
Notes
Aspirin 75mg dispersible tablets[s]
1 per day
7 tablets
To be continued
Atenolol 50mg tablets[t]
1 per day
7 tablets
To be continued

Follow on Plan[section 7]

  1. Chest pain advice leaflet given and explained
  2. Smoking advice given
  3. Cardiac Angiography – scheduled for 2 weeks hence[u] (20-May-2006 10:00)
  4. Fasting glucose[v] (booked for following day - 06-May-2006 11:20)
  5. Fasting Lipids[w] (booked for following day - 06-May-2006 11:20)