The patient is an 87-year-old man with chronic ischemic heart disease, mild pulmonary
disease, and mild renal insufficiency. He is followed by me and by Dr. [Jason Chu] as his
primary outside physician. The patient is 16 years status post coronary bypass surgery
with good results with no recurrent infarction and no significant recurrent angina. He has
mentioned mild renal insufficiency. Runs a creatinine of close to 2, at times worse, at
times better. GFR estimated 41. He has had intercurrent bronchitis, which is cared for by
Dr. Chu. He has chronic prostate cancer, runs a high PSA of 24, followed by Dr. Heine.
New complaint at time of this visit is essentially he is putting on fluid. His belt feels tight.
His weight is currently 81 kg. Old weight is not available right now. Of note, his recent
BMP is 240. No recent electrocardiogram to review. He still walks without trouble for his
age. He is New York Heart Association functional class 1.
REVIEW OF SYSTEMS: Times 10 since last visit 4 months ago, otherwise unchanged
with no interval health problems.
PHYSICAL EXAMINATION: Blood pressure 160/75, pulse 60 and regular.
HEENT: Negative.
NECK: No carotid bruits, no neck vein distention.
CHEST: Clear to percussion and auscultation. Well-healed [sternotomy] scar.
CARDIAC EXAMINATION: Sinus rhythm, no murmur, rub, gallop, heave, or thrill.
PMI at the MCL.
ABDOMEN: Soft, slightly obese. Bowel sounds present. No masses, no bruits. No
pulses ***.
Distal pulses not palpable. Feet are warm. There is 1+ edema.
IMPRESSION: Chronic ischemic heart disease, mild chronic renal insufficiency stage 3.
Chronic lung disease, mild. New complaint of a sense of fullness with a slightly elevated
BMP. We will try to check his thoracic impedence with a Bio-Z to see if he is fluidoverloaded.
25 minute face-to-face encounter, more than half counseling the patient about his
condition and then diagnostic and therapeutic plan. For now, we will continue his
medications, which consist only of Coreg 6.25 mg a day and aspirin 81 mg a day.