Dids, I´ll try to help; I will translate this epicrisis into plain english (not so medical) so you can understand what you had.
Cardiocirculatory: Without shortness of breath at rest (orthopnea), no neck vein distention (jugular distention), edema without fovea (a skin depression when you press the edema to the bone o muscle) up to the knees, peripheral pulses present and symmetrical. Auscultation: Rhythmic tones without audible murmurs.
Respiratory: Eupneic (normal respiratory rate), pulmonary auscultation: normal breath sounds without any other pathological sounds.
Abdomen: Tender, no muscular defense, preserved peristaltic movement, discomfort on the right hypochondrium.
Neurological: Without meningeal signs, preserved superior mental functions, normal muscular tone without motor focus.
ECG: Sinus rhythm, normal PR segment, normal QRS complex, ST depression of 1 mm in anterior leads, lack of R progression in precordial leads.
Progress note: We tell the patient that she must remain admitted at the hospital due to the suspicion of a high risk angina. More tests are required not accessible in the emergency department. The patient requests to be discharged voluntarily so she can get back to her country. We inform her that she can suffer a new episode of angina or even a heart attack. The patient understands the possible complications that this discharge can have, nevertheless she signs her discharge.
Working diagnosis 1: High risk angina
Working diagnosis 2: Heart failure
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Quote:
An expert is a man who has made all the mistakes which can be made in a very narrow field.
Niels Bohr
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