CHIEF COMPLAINT: Followup regarding blood work.
HISTORY OF PRESENT ILLNESS: The patient is a 77-year-old male who was recently
seen by her cordialigst Dr. Leff with a normal checkup. The patient does have a history
of coronary artery decease, status post spend placement, but she denies any chest pain,
palpation or shortness of breast. He does have nitroglycerin, but he states he has not
needed to use it.
He also has hyperlipidemia for which he is on Love statin and his most recent liver
profile was well controlled with an LDL being at 60 and 5. He denies any myalgias with
taking Zocor or weakness.
He does complain of a right knee pain and he does have severe degenerative joint disease
with bone changes. He does take Tylenol as needed for pain and he has voided over-thecounter NSAIDs as he has some borderline renal sufficiency. The patient denies any
dysoria, hematuria, frequency or nocturia. He does have occasional hesitancy. The
patient states he is unable to urinate spontaneously without problems.
He also has hypothyroidism for which he is on Levothyroid 50 mg daily; however, his
TSH is borderline high at 4.90 in 03/2008. He denies any significant cold tolerance,
constitution or fatigue.
ALLERGIES: No known drug allergies.
MEDICATIONS: Zocor 40 mg daily, Hizack 100 mg daily, levothroxine 50 mcg daily,
which we are increasing to 1-1/2 tablets alternating with 1 tablet daily, atenolol 25 mg
daily, aspirin 81 mg daily, nitroglycerin p.r.n., Tylenol p.r.n. and he is going to do a trial
of glucosamine/chondroitin daily as well as Flomax 0.40 mg daily.
PAST HISTORY: Coronary artery disease status post stand placement x3, degenerative
joint disease involving his right knee, hypothyroidism, hypolipidemia, hypertension, BPH
and erectile dysfunction, history of lumbar decompressive surgery with fusion in
05/2007, a right rotator cuff tear repair and hemorrhoidectomy.
PAST SURGICAL, SOCIAL AND FAMILY HISTORY: Has not changed since my not
on 12/19/2008. Please refer to that.
REVIEW OF SYSTEMS: As per HPI. The patient does complain of some left knee
pain, mostly behind the knee rotating down into his leg. He denies any swallowing. He
denies any fevers, chills or abdominal pain.
PHYSICAL EXAMINATION:
VITAL SIGNS: Blood pressure 136/63, pulse 15, respiratory rate 60, O2 saturation 93%
on room air, pain 5 on a scale of 10 regarding the left leg. Weight 244 pounds.
GENERAL: The patient is an elderly overweight male in no acute distress.
CARDIOVASCULAR: S1, S2, regular rate and rhythm.
RESPIRATORY: Clear to auscultation bilaterally.
ABDOMEN: Soft, nontender, bowl sounds positive, no bruits.
MUSCULOSKELETAL: Left knee, positive trepitus. No significant pain with flexion
or extension, no swelling was noted.
Laboratory data dated 03/06/2008 showed BUN and creatinine of 37 and 1.37 with a
glucose 93. LFTs within normal limits. Total cholesterol 180 LDL 65, HDL 38 and
triglycerides 89. TSH borderline high at 4.90
IMPRESSION:
1. Hyperthyroidism with borderline control. We will be increasing the patient's
levothyroxine as noted above.
2. Hypolipidemia, controlled.
3. Left knee pain, most likely secondary to degenerative joint disease. We will be
getting an x-ray of the left knee as well. I told the patient do a trial of glucosamine and
chondroitin. The patient to continue with his Tylenol. I told the patient, however, if the
Tylenol is not controlling his pain, he is to notify me and we can do a trial of something
such as tramadol or one of the narcotics.
4. Coronary artery disease, stable.
5. Hypertension with nephropathy. The patient's creatinine is 17.7, which is borderline.
We will be getting a renal artery ultrasound to check for stenosis as well as a renal
ultrasound as well as checking a urinalysis. As his BUN is mildly high, we will be
checking stool occults x3 to screen for any GI breeding, although the patient denies any
abdominal pain, melena, hematochezia or reflex. The patient otherwise is to continue
with his current blood pressure regimen.
The patient to follow up in 2 months however I told the patient if he gets any sort of test
done by me, to notify me if he has not heard the results within 2 weeks of having them
done.
We will also be getting a repeat TSH in approximately 6 weeks.