Document MJ00qN4Qd5enDVQjKBjXynY19

CHC 000024 nmv FOLLOWUP NOTE Name ofPatient: Deane Smith Medical Record No.: 6759/4202 Date ofVisit: 10/03/08 History of Present Illness: The patient is an 80-year-old male who has cardiovascular reevaluation and pacemaker interrogation for hypertensive cardiovascular disease with coronary artery disease, mitral regurgitation, and tricuspid regurgitation, as well as chronic atrial fibrillation on Coumadin anticoagulation therapy. Since his last evaluation, foe patient has had no chest pain or dizziness, complains of shortness of breath with walking uphill but no change in symptoms from his previous evaluation. The patient had a previous coronary angiography demonstrating coronary artery disease with 50% LAD, 40% circumflex, and 25% RCA stenosis. His last stress echo from September 2007 revealed abnormal stress echocardiogram with apical-septal hypokinesis and mild to 2+ mitral regurgitation and moderate 3+ tricuspid regurgitation. At that time, the results of the stress test were discussed with the patient and medical therapy was chosen. Medications: Medications were reviewed with this patient and include Lipitor 10 rag 1/2 tablet Monday, Wednesday, and Friday, Toprol 50% mg b.i.d. but had been increased in his last visit to 200 mg from 75 mg, Dyazide 37.5/25 mg daily, lisinopril 2.5 mg daily, Coumadin 2 mg as directed, and multivitamin and vitamin C supplement He has tolerated Coumadin anticoagulation without evidence of GI, GU or ENT bleeding. Review of Systems: Review of systems Is otherwise negative and reveals no fever, chills, sweats, significant blood loss, weight gain, or weight loss. The patient denies changes in GI or GU function to suggest bleeding. He has had no thromboembolic phenomenon. Physical Examination: General: On physical examination, this is a currently comfortable and well-appearing male. Vital Signs; Weight: Decreased by 9 pouneb to 186. Blood Pressure: 130/80. Pulse: 60 and regular. BMIis27.5. Cardiac Examination: Reveals regular rate and rhythm. SI, S2 are normal. There is a 2/6 holosystolic murmur present at the apex and a 2/6 systolic ejection murmur present at the lower left sternal border. Abdomen: Soft, nontender. ' CHC 000024 D-1079 CHC 000025 Smith 10/03/08 Extremities: Have a trace of pedal edema bilaterally. Pedal pulses palpable. Neurologic Examination: The patient is alert and oriented with appropriate mood and affect. Diagnostic Data: Pacemaker interrogation reveals chronic atrial fibrillation with ventricular pacing about 60% and sensing 40%. The patient has had 3 episodes of tachycardia. Rate improved from previous interrogation with the increase in beta-blocker. Impedance is stable and battery life is adequate. Normal function pacemaker is present. Laboratory data reveals normal electrolytes and kidney function, normal liver enzyme, total cholesterol of 140, triglycerides of S3, HDL of 63, and highly favorable LDL of 66. Hemoglobin Ale is slightly elevated at 6.2; this was being followed by his primary care physician. Dr. Marmoistein, and will be repeated in 3 months. The patient was told to increase activity and limit carbohydrates, mid ifpossible lose some weight to reach a BMI of25. INR today is 2. The patient will continue on same Coumadin dose. Impression and Plan: The patient has arteriosclerotic cardiovascular disease with hypertension, hyperlipidemia, and atrial fibrillation. The echo from September 2008 reveals normal left ventricular size with left ventricular ejection fraction visually estimated at 40% which is slightly decreased from his previous ejection fraction, anteroapical and septal-apical hypokinesis which were present previously, mild to moderate mitral regurgitation, and moderate to severe tricuspid regurgitation with pulmonary hypertension. I have recommended continuing on Topiol for rhythm control, continue on Dyazide for leg edema, lisinopril for frill blood pressure control, and repeat his protime and INR in Arizona. The patient is leaving for a few months and will have a clinical and laboratory reevaluation when he returns in December. If he has deterioration in symptoms before that, he will seek medical help in Arizona. ILSE-MARIE REICHERT, ARNP ' IMR/acl/pac/rbl Page 2 of2 CHC 000025