daniel
True Blue
Base this on History and MDM.
What level.
She is a 56-year old female presenting with a couple of weeks of a heavy sensation in her chest, particularly on work days when she is at work. She works for a dentist. She does yoga and other exercises, which actually relieves her symptoms. She is not having any radiation of pain or respiratory symptoms. She does have a history of hyperlipidmia, however, and is on Zetia.
She denies any shortness of breath, wheezing, cough, etc.
Ekg ordered-reviewed: normal sinus rhythm. There is no change from November 2, 2005.
Assement: Chest tightness, most likely stress-related
Recommend a trial of Lexapro and continuing with excersise. Will follow up in about three weeks, sooner if her symptoms escalate or they become exertionally-related.
What level.
She is a 56-year old female presenting with a couple of weeks of a heavy sensation in her chest, particularly on work days when she is at work. She works for a dentist. She does yoga and other exercises, which actually relieves her symptoms. She is not having any radiation of pain or respiratory symptoms. She does have a history of hyperlipidmia, however, and is on Zetia.
She denies any shortness of breath, wheezing, cough, etc.
Ekg ordered-reviewed: normal sinus rhythm. There is no change from November 2, 2005.
Assement: Chest tightness, most likely stress-related
Recommend a trial of Lexapro and continuing with excersise. Will follow up in about three weeks, sooner if her symptoms escalate or they become exertionally-related.
