1995 & 1997 DOCUMENTATION GUIDELINES
56 Y/O man who was admitted yesterday because of unstable angina CCS class III in the last 1 month. He has been having recurrent C/P overnight awakening him from sleep requiring multiple NTG puffs. +ve SOB & sweating. P/Ex: 170/85, 95/min reg. 90% O2 Sat on 2L FiO2. Chest: bilateral basal crackles. JVP: 5cm ASA with +ve AJR. ................
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