Document v1OQzbv6zj94jygmemRB9aN2R

SMC 000206 .. ... o SMITH, DEANE R. 6/28/03 Follow-up office visit 5/28/2003 for the fblowlng medical problems: 1) atherosclerotic cardiovascular disease with coronary artery disease, 50 percent LAD, 40 percent circumflex stenosis, 2) LV ejection fraction 45 percent, 3) chronic atrial fibrfllation. 4) chronic Coumadin anticoagulation, 5) right bundle branch block with left posterior fascicular block. Since previous evaluation, (he patient has had medical evaluation for progressive fatigue, exertional intolerance, palpitations, and weakness. Hotter monitor revealed significant tachybrady syndrome with peak heart rates as high as 180 190 beats per minute, and multiple 2.0-2.7 second pauses. I have discussed tachycardia-bradycardia syndrome with the patient and his wife and I have recommended consideration for permanent pacemaker. REVIEW OF SYSTEMS: Reveals no fevers, chills, sweats, recant acute blood loss or weight loss. He denies orthopnea, pedal edema, or syncope. He has tolerated Coumatfln without evidence of Ql, QU, or ENT bleeding. He has had surgical evaluation for breast man and surgical excision has been recommended. I recommended pacemaker Insertion be times to correlate after his surgical wound has time to heal. PHYSICAL EXAMINATION: GENERAL: VITAL SIGNS: HEENT: LUNGS: CARDIAC: ABDOMEN: EXTREMITIES: Reveals a comfortable and well-appearing male. Blood pressure Is 128/86. Pulse Is 70 and regular. Respiratory rats is 16. Normocephallc, atraumatic cranium. Jugular venous pressure is normal with irregular contour. Carotid upstroke is +2 Naterally. Lungs are dear. Reveals an Irregularly Irregular rhythm. Si and S2 are normal. A 2/6 apical mtnr is present Reveals a soft and nontender abdomen. No edema IMPRESSION: The patient has chronic atrial fibrillation with well-controlled risk prevention management with Coumadin therapy. He has moderate mitral regurgitation and noncritical coronary artery disease. He Is at significant risk, ho.vo-sr. both from tachycardia and bradycardia and I have recommended placement of permanent pacemaker to rrrirr ize bradycardia and then addition of digoxin or selected antianhythmic therapy to optimize protection against tachycardia. "r.e risks, benefits, expected outcomes, and alternatives from pacemaker therapy have been recommended and the patient is agreeable to these recommendations, to be performed following breast nodule exdston. Laboratory panel reveafc a noma) hematocrit, glucose, electrolytes, cholesterol, TSH, and SCOT. Follow up in four to six weeks, sooner If necessary for symptomatic deterioration,' PRK/cmt Peter R. Kures, M.D. cc: Barry Marmorstein, M.D. Daniel Pepper, MJD., PLLC / SMC 000206 D-1067