Documenting a cardiology round
Post-MI ward notes, angiogram and PCI reports, TOE and stress echo reports, the discharge summary and the letter back to the GP.
Day two after an NSTEMI
Day two post NSTEMI. Chest pain free. In AF, rate controlled.
Obs: heart rate seventy-two in AF, BP one twenty-four on seventy-six, sats ninety-seven on room air. Heart sounds dual, chest clear, no peripheral oedema.
Trop peaked at 1,840, 960 this morning. Cr 98, K 4.1. Angio yesterday, 80% mid LAD, one DES. Echo EF 50% with mild anterior hypokinesis.
Impression: NSTEMI with mid LAD PCI, AF.
Aspirin to stop after seven days, clopidogrel 75 daily for twelve months, apixaban 5 BD. Atorva 80. Start ramipril 2.5 and metoprolol 25 BD.
Cardiac rehab referral, home tomorrow if she stays settled.
Procedure reports
Four of the starter templates are cardiology procedure reports. The angiogram and catheter reports are dictated in the lab at the end of the case.
At discharge
- Discharge summary
- The infarct, the stent, the echo result and the reconciled medication list, with the stop date for each antithrombotic: aspirin at day 7, clopidogrel at 12 months, apixaban continuing.
- Letter to the GP
- What to check and when: renal function and potassium a week after ramipril starts, fasting lipids at 6 weeks against the post-ACS LDL target below 1.4 mmol/L with at least a 50% reduction, and the cardiac rehabilitation booking.
- Letter to the referrer
- Where the patient came from another physician: the angiographic findings, the PCI and who follows the AF from here.
