DIALOGUE

[doctor] russell ramirez is a 45 -year-old male with past medical history significant for cad status post prior status post prior rca stent in twenty eighteen hypertension and diabetes mellitus who presents for hospital follow-up after an anterior stemi now status post drug-eluting stent and lad and newly reduced ejection fraction ejection fraction thirty five percent and moderate mitral regurgitation alright russell hi how are you doing today
[patient] hey document i i do n't know i'm doing alright i guess
[doctor] just alright how's it
[patient] well
[doctor] how's it been since you've had your heart attack have you been have you been doing alright
[patient] no i've been seeing you for years since i had my last heart attack in two thousand eighteen but i've been doing pretty good i ca n't believe this happened again i mean i'm doing okay i guess i just feel tired every now and then and but overall i mean i guess i feel pretty well
[doctor] okay good were you able to enjoy the spring weather
[patient] yeah some i mean i'm hoping now that i've had my little procedure that i'll feel better and feel like getting back out and and maybe doing some walking there is some new trails here behind the rex center and maybe get out and walk those trails
[doctor] that will be fine i know you love walking the trails i know you like looking at the flowers because i think you you plant a lot of flowers as well do n't you especially around this time
[patient] yeah i do some gardening around the house
[doctor] yeah
[patient] and you know i really like photography too being able to go out and take nature pictures
[doctor] yeah
[patient] so i'm hoping to be able to go out and do that
[doctor] okay well we'll we'll do what we can here to get you out and going doing all those fun activities again now tell me have you had any chest pain or any shortness of breath
[patient] no not really no chest pain or shortness of breath i've been doing some short walks right around the house so like around the block
[doctor] okay
[patient] but i stay pretty close to the house i've been doing some light housekeeping and i do n't know i seem to be doing okay i think
[doctor] okay alright now tell me are you able to lay flat at night when you sleep or
[patient] well i mean i i never have truly laid flat on my back i've always slept with two pillows which is normal for me
[doctor] okay
[patient] so i mean i guess i really do n't have any troubles with my sleeping
[doctor] okay good how about are your legs swelling up
[patient] nope i've always i always had skinny ankles like like i got dawn knots legs
[doctor] well that's cute were you able to afford your medications and are you taking them as prescribed
[patient] yeah i've been taking my medicine i got pretty good insurance there through the plant and and so the co-pay is n't too bad
[doctor] okay
[patient] and i've been taking them because i do n't want my sense to close up and they told me that that to take them this you know all the time and and i've been taking them since i got out of the hospital
[doctor] okay well very good i'm glad you're doing that good for you russell and and then please keep that up now tell me are you watching your salt intake and trying to change your diet
[patient] yeah so when i was in the hospital they said something about my way my heart pumps now
[doctor] mm-hmm
[patient] it it's it's a little low and i might keep fluid on my legs if i'm not careful
[doctor] right
[patient] and it's gon na be hard because you know i i really do like pizza and and they told me that i'm really gon na have to watch salt and they said that there is a lot of salt and pizza
[doctor] there is a lot of salt and pizza and you know and you're gon na have to be able to avoid all the other salty foods as well so and i know that's hard but it's very important for your heart to be able to function at it's best right and you wan na be able to get out and walk you know walk take those walks again at the park and then you know do your photography so in order to do that we're gon na have to really cut back on those okay
[patient] well
[doctor] alright so why do n't we go ahead and do a quick physical exam on you here i just want to take a look at you your vital signs look good i'm glad to see you're tolerating the medication well i'm gon na go ahead and feel your neck here i do n't appreciate any jugular venous distention and there are no carotid bruits on your heart exam there is a three out of six six systolic ejection murmur it's heard at the left base but that's pretty much the same as last year so we'll continue to monitor that okay let me listen to your lungs here real quick russell your lungs are clear so good good and your extremities i do n't see any swelling or edema on your right radial artery the cath site there is clean and it's dry and intact and i do n't see any hematoma so that's good and there is a palpable rra pulse so russell i did review the results of your ekg which showed normal sinus rhythm good r wave progression and evolutionary changes which are anticipated so let's go ahead and talk about my assessment plan for you for your first diagnosis of coronary artery disease we are gon na have you continue your your aspirin eighty one milligrams daily and brilinta ninety milligrams twice daily and we're gon na have you continue on that high dose statin that atorvastatin you might call it lipitor eighty milligrams daily and then also continue on that toprol fifty milligrams daily okay and i'm also going to refer you to cardiac rehab so for you to get some education about your heart and also give you the confidence to get back exercising regularly now i know patients love the cardiac rehab program i think you will do well does that sound good to you
[patient] that sounds good document
[doctor] alright so for your second diagnosis here the newly reduced left ventricular dysfunction and moderate mitral regurgitation i think your pumping function will improve in time you know they got you to the lab quickly so i think that heart muscle is just stunned and you're very compliant you're very good with your medications and following through with those so i think it will recover so that said i want you to go ahead and continue continue your lisinopril twenty milligrams a day i do n't think you need a diuretic at this time but i do want to add aldactone twelve . five milligrams daily and then you'll need to get labs next week okay and then we're gon na repeat another echocardiogram echocardiocardiogram in about two months
[patient] okay
[doctor] okay and then for your hypertension your third diagnosis of hypertension i want your to take your blood pressure just like you would you know every so often and then because your blood pressures actually seem fine at this time so we will continue to monitor that and i think you will tolerate the aldactone well as well
[patient] alright sounds good document
[doctor] okay well you take care and you have a good evening
[patient] yeah you too
[doctor] bye

CLINICAL NOTE

CHIEF COMPLAINT

Hospital follow-up after an anterior STEMI.

MEDICAL HISTORY

Patient reports history of CAD status post prior RCA stent in 2018, hypertension, and diabetes mellitus.

SURGICAL HISTORY

Patient reports history of RCA stent in 2018 and most recently underwent drug-eluting stent placement in the LAD.

SOCIAL HISTORY

Patient reports enjoying walking outside, gardening, and nature photography.

MEDICATIONS

Patient reports taking aspirin 81 mg daily, Brilinta 90 mg twice a day, Lipitor 80 mg daily, Toprol 50 mg daily, and lisinopril 20 mg a day.

REVIEW OF SYSTEMS

Constitutional: Reports fatigue. Denies changes in sleep.
Cardiovascular: Denies chest pain.
Respiratory: Denies shortness of breath.
Musculoskeletal: Denies lower extremity swelling.

VITALS

Vital signs look good today.

PHYSICAL EXAM

Neck
- General Examination: No carotid bruits.

Respiratory
- Auscultation of Lungs: Clear bilaterally.

Cardiovascular
- Auscultation of Heart: Grade 3/6 systolic ejection murmur, heard at the left base.

Musculoskeletal
- Examination of the right upper extremity reveals no swelling or edema on the right radial artery. Cath site is clean, dry, and intact. No hematoma. Palpable right radial artery pulse.

RESULTS

Electrocardiogram is reviewed and revealed normal sinus rhythm with good R wave progression and evolutionary changes, which are anticipated.

ASSESSMENT AND PLAN

1. Coronary artery disease.
- Medical Reasoning: The patient's exam is consistent with coronary artery disease.
- Patient Education and Counseling: We discussed that he should continue to watch his diet and salt intake. We also discussed that the cardiac rehab should help with his confidence with exercising regularly and for his education.
- Medical Treatment: Continue taking aspirin 81 mg daily Continue taking Brilinta 90 mg twice a day. Continue taking Lipitor 80 mg daily. Continue taking Toprol 50 mg daily. I will refer him to cardiac rehab.

2. Newly reduced left ventricular dysfunction and moderate mitral regurgitation.
- Medical Reasoning: The patient's physical exam is consistent with this diagnosis.
- Patient Education and Counseling: We discussed that his pumping function should improve in time. We also discussed that since he is compliant with his medications and presented to the cardiac cath lab quickly, he should recover. I advised the patient that he does not need to start a diuretic at this time.
- Medical Treatment: Continue taking lisinopril 20 mg a day. Prescription for Aldactone 12.5 mg daily provided. Order for labs provided. Repeat echocardiogram ordered to be completed in 2 months.

3. Hypertension.
- Medical Reasoning: This seems stable at this time.
- Medical Treatment: Continue home blood pressure monitoring.

Patient Agreements: The patient understands and agrees with the recommended medical treatment plan.