Document DGr8EbzJ5E70p8JLEXBYM8L9o

CHC 000033 r DATE OF SERVICE: PATIENT NAME; MRN#: June 7,2007 DEANE SMITH 6759 HISTORY OF PRESENT ILLNESS: The patient has cardiovascular reevaluation for atherosclerotic cardiovascular disease with coronary artery disease 50% LAD, 40% circumflex, and 25% right coronary artery m 2002. He has chronic atrial fibrillation with bradycardia and has bad permanent pacemaker implantation. Permanent pacemaker today reveals normal functioning single-chamber ventricular pacemaker. It is of note that he has increased ventricular response during his peak physical activity with heart rates greater than ISO. He has no angina. He has noted exertional dyspnea and fatigue. He has continued on Coumadin anticoagulation without evidence of GI, GU, or ENT bleeding. He has no focal numbness, weakness, headaches, visual, or speech disturbance to suggest stroke. PAST MEDICAL HISTORY: 1. Atrial fibrillation with chronic Coumadin anticoaguiation. 2. Coronary artery disease. 3. Status post permanent single-chamber pacemaker. 4. Lower extremity pain consistent with exertional intolerance and claudication. MEDICATIONS: Medications were reviewed include Coumadin, Lipitor, Dyazide, and Toprol-XL 25 mg p.o. q.d. PAST SURGICAL HISTORY: Significant for polypectomy. PHYSICAL EXAMINATION: Physical examination reveals a comfortable and well-appearing male. Blood pressure is 128/60, pulse is 60 and regular, and respiratory rate is 16. HEENT reveals normocephalic and atraumatic cranium. Jugular venous pressure is normal with a regular contour. Carotid upstroke is +2 bilaterally. Lungs are clear. Cardiac examination reveals a regular rate and rhythm. SI and S2 are normal. A 2/6 holosystolic murmur is present at the apex. Abdominal examination reveals a soil and nontender abdomen without organomegaly or masses. Extremities reveal no edema. Distal pulses are +2 bilaterally. Neurologic examination reveals that the patient is alert and oriented with appropriate mood and affect. IMPRESSION AND PLAN: The patient has atherosclerotic cardiovascular disease with non-critfeally obstructive CAD and exertional dyspnea. Pacemaker interrogation reveals rapid ventricular response to chronic atrial fibrillation. 1 have recommended increasing Toprol-XL to 50 mg p.o. b.i-d. I have recommended consideration for addition of digoxin therapy if pacemaker interrogation in 3 months reveals continued elevations in ventricular response. Addition of low dose nitrate therapy can be useful fix' preload reduction if chest pressure or angina symptoms accompany peak activity and tachycardia. Clinical reevaluation is recommended within 3 months. Laboratory reassessment and pacemaker Peter Kures, M.D. CC: Dr. Barry Marmorstein CHC 000033 - D-1073