TODAY'S OFFICE VISIT: Patient is a 78-year-old man with a long
history of severe arthrosclerotic [arterialized] atherosclerosis.
He is many years status post anterior and lateral [cranial]
infarction when he lived in Hong Kong. He has, since then,
decreased ejection fraction, anterior scar. Approximately 4
years ago he presented with an abdominal aortic aneurysm and
pending rupture. Had that successfully repaired. 2 years ago he
had an inferior wall myocardial infarction requiring a stent.
Since then he has done well except for the intercurrent kidney.
He is maintained on polypharmacy for his heart failure,
hypertension, hyperlipidemia, gout, and his congestive heart
failure on Coreg, aspirin, Aldactone, allopurinol, lisinopril,
and Lasix. As well, he takes Flomax for BPH. No other
intercurrent health problems. He does surprisingly well given
all of these underlying issues. The past many months have been
uneventful with no new problems since the kidney stone.
PHYSICAL EXAMINATION: Blood pressure is 102/60, pulse is 60.
is breathing comfortably and looks well.
HEENT: Negative.
NECK: No carotid bruits. Normal upstroke.
CHEST: Clear to percussion and auscultation. No adenopathy.
CARDIAC EXAMINATION: Sinus rhythm, normal 1st and 2nd heart
sound. No murmur, rub, gallop, heave, or thrill.
ABDOMEN: Reveals a transverse scar from his previous surgery.
Bowel sounds present, no masses. Femoral pulses are full.
Distal pulses are intact. There is no edema.
NEUROLOGICAL EXAM: Was normal. His mentation is normal.
He
IMPRESSION: Complicated history of diffuse vascular disease with
3 major vascular events of acute myocardial infarction, remote,
and more recent inferior infarction, and in between a triple
aneurysm repair. At this point will continue current
medications. 25 minute face-to-face encounter with him and his
daughter, more than half discussing his medical problems and the
therapeutic plan.
-----------------------------------------------The patient is a 74-year-old woman known to me for possibly a
decade for problems with hypertension, hyperlipidemia, and
coronary artery disease approximately 5 years ago. She had
somewhat atypical symptoms of angina pectoris with aching into
her jaw and primarily manifests as aching in her jaw. She at
that time had angioplasty of her right coronary anatomy and a
stent placed with good result. Last year, she had recurrent
symptoms, and was noted to have complex stenosis in her left
anterior descending coronary artery, but she also had a jugular
venous stent placed. Since then, she has been maintained on
aspirin products, Vitorin, HCTZ, atenolol. Her jaw symptoms have
resolved. She has persistent problems with easy bruisability,
probably due to the aspirin and Plavix. We discussed this issue
at 1 year from her last stent, which will be in May. She will
stop the aspirin, continue the Plavix. Other problems relate to
around persistent weakness in her legs, which she thinks may be
related to the Vitorin, since she has weakness and aching out of
proportion to the exercise she does. No definite evidence of
spinal stenosis. Nothing to suggest polymyalgia rheumatica. She
will, at this time stop the Vitorin. If her symptoms improve, we
will try Crestor on a twice a week basis if her symptoms do not
improve, we will look further for such problems as spinal
stenosis.
SYSTEM REVIEW X10: Otherwise noted for negative ENT exam. A 10
percent hearing loss. No other major medical problems on review
of systems x10 since the last encounter 4 months ago. No recent
laboratory or cardiac or imaging studies.
PHYSICAL EXAM:
On physical exam today, as always she looks younger than her
stated age and looks well. Is comfortable except for weakness in
her legs. No deficits except for the weakness and some aching in
her legs.
VITAL SIGNS: Are stable. Blood pressure 138/75, pulse 60.
HEENT: Negative.
NECK: No carotid bruits.
CHEST: Clear to percussion and auscultation. No adenopathy.
CARDIAC EXAMINATION: Sinus rhythm, normal 1st and 2nd heart
sound. No murmur, rub, gallop, heave, or thrill.
ABDOMEN: Soft, no masses, no bruits. Bowel sounds normal.
Pulses palpable throughout. No bruits, no edema.
IMPRESSION: Hypertension CAD, possible myalgia from statin.
minute encounter face-to-face, 1/2 counseling her about her
problems and how we might proceed with workup and medicine
change.
25-