DIALOGUE

[doctor] next patient is nicole miller . date of birth is 09/18/1949 . patient was called for a follow-up with me for chronic congestive heart failure with diastolic dysfunction . bmp's been , uh , 3,000 in march , and is about six- was up to 6,000 in april . she was increasingly dyspneic . we changed her furosemide and torsemide 20 milligrams by mouth daily . uh to note , the patient is not currently on potassium supplement . her lisinopril had- has also been increased up to 10 milligrams daily in march . also did when i saw her last april . she reported being interested in having her right knee replaced this summer at east metro . it was recommended that we work to control her cardiovascular status before surgery .
[doctor] hey , miss miller , how are you today ?
[patient] i'm doing okay , thank you .
[doctor] i asked you to come in today because we want to keep- we want you to have this knee surgery this summer but we want to keep a close eye on you to make sure a week before your surgery you do n't suddenly go into congestive heart failure and it gets postponed .
[patient] yeah , that would not be good .
[doctor] i see you're scheduled on the 24th for surgery .
[patient] yeah , that's right .
[doctor] okay , good . well it looks like you have lost about 3 , 3 and a half pounds since i saw you last in april . some of that might be water weight , but still , this is positive .
[patient] yeah , i noticed that too . i think the oxyglutinine is helping as well . my urgency to use the bathroom is much better .
[doctor] well that's great .
[patient] yeah , i , i'm pleased about it too .
[doctor] you ever get leg or finger cramps or anything like that ?
[patient] yeah , i had leg cramps the other day , but i thought it might , was maybe just because i was cold as i had my ceiling fan on and fell asleep . i had cramps when i woke up in both legs right here . um i drank pickle juice and it went right away .
[doctor] well do n't , do n't get crazy with the pickle juice because all of the salt in it .
[patient] haha , i know , i only drink about 4 ounces or so .
[doctor] okay good .
[patient] um it went away so i did n't drink anymore . i find it works a lot better than trying to put some cream on my leg .
[doctor] sure just , just keep it in moderation .
[patient] okay .
[doctor] and then are you still on an iron supplement ? and are you using the bathroom okay ?
[patient] uh yes , everything is good .
[doctor] good . how is your heart burn doing ? any problems with that ?
[patient] no , it did get bad for a while so i tried to take some prilosec and then stopped that other one .
[doctor] okay .
[patient] um i did that for like , gosh , i think it was two weeks back in january and have n't had any problems since .
[doctor] great .
[patient] um and after i stopped taking that um i went back to the stomach one , so i'm doing good now .
[doctor] okay and you're still due for a colonoscopy , correct ?
[patient] uh yeah , that's right .
[doctor] all right , let's review your blood work real quick . i checked your hemoglobin level because you have had some anemia in the past but that is still doing great .
[patient] good , that's a relief to hear .
[doctor] your potassium is 3.9 so it's holding steady on the torsemide . your creatinine was .7 not .8 so you're doing well with kidney numbers . your bun may be a tiny bit elevated at 23 which is the number we look for for dehydration sometimes the kidneys , but it's not terrible . um so when i look at your numbers as a whole i think you're tolerating the torsemide okay at the current dose . i also sent out to look at the heart failure number- i sent to look at your heart failure number . there is a test called a bmp that i was monitoring and in march it was up to 3,000 and then went up to 6,000 in april before i made the change . i'm still waiting for those results .
[patient] okay .
[doctor] all in all i think you're doing good on paper though .
[patient] what about , um what's it called , a1c ? does that show up ?
[doctor] um i do n't think i ordered it but i could . your last a1c was 5.5 in march .
[patient] all righty .
[doctor] so your blood sugar is a little bit high , it was 169 today but that kind of depends on what you ate and you were n't fasting for the blood check so i might have to repeat that test for pre-op , but i do n't think we need to do it today .
[patient] all righty that sounds good .
[doctor] i checked your magnesium level because sometimes you uh urinate out magnesium with the water pills but it was normal at 1.7 and your blood pressure is also looking good .
[patient] okay great . that all sounds awesome .
[doctor] all right let's take a quick listen .
[doctor] use my general physical exam template .
[doctor] and take a couple of deep breaths for me .
[doctor] your lungs sound pretty good to me so keep doing what you're doing . um uh , like i said , i think you're doing good overall but let's just talk about a few things .
[patient] all righty .
[doctor] so we often like to keep people with heart problems on magnesium and get their levels up to around the 2-ish range . yours is a little bit less than 2 and we want that 2-ish range because it can help stabilize the heart muscle . so i might recommend putting you on magnesium supplement . it's supposed to be twice a day so that's kind of annoying , but i know you're on other medicines twice a day too , so i think you'll do fine .
[patient] yeah , that'll be okay .
[doctor] great . now before surgery we'll have to get you off your clopidogrel for a week beforehand .
[patient] yes , okay , i have everything written down on my phone , and i have a letter taped to the side of my bed to remind me .
[doctor] perfect ! we will give you a reminder as well . we will also need to complete a pre-op check within two weeks of your surgery during the first or second week of june .
[patient] okay , i'll put that down .
[doctor] you might also have to repeat an ekg before surgery which we could do today . i know i'm sure it feels like you're doing , you're always doing ekgs . um we do n't need to any x-rays of your chest because you had one recently , and we do n't need any more blood work because we did that today .
[patient] yeah , i do a lot of ekgs . i'm basically a regular . but i'm happy to do one today , no problem .
[doctor] lastly , once we get your knee surgery , um we , we should think about getting you a colonoscopy . we can do it here locally because you have medicare . do you have private insurance also ?
[patient] yeah , i have both .
[doctor] okay so yes , you can get it , your colonoscopy , wherever you'd like .
[patient] okay , well my husband's insurance may be running out . might we be able to get the procedure done sooner ? maybe in the next 30 days ? is that okay ?
[doctor] um i can put it in right now for , uh , for county for the next 30 days , and they might be able to get you in within the next few weeks . it should not take , it should not make you ineligible for the surgery . in other words completing a colonoscopy would not delay your surgery .
[patient] okay , good .
[doctor] so let me see . i've been doing one of two things at every one , and everyone is great so it depends more on timing availability of their or for the colonoscopy . we can send you to dr. martin for the surgery who is at county surgical services down here or the other option is valley medical , and they do it at springfield .
[patient] okay , that sounds good .
[doctor] i think either direction they're good technicians of the colon .
[patient] okay , yeah whatever you can get me in , that works great .
[doctor] so i'll call around . now if you get that done and they tell you 10 years then you'll be good to go .
[patient] great , thank you .
[doctor] you're welcome . have a great day . let us know if you need anything else , okay ?
[patient] sounds good .
[doctor] all right , assessment and plan .
[doctor] chronic chf . mixed presentation . had a exacerbation of cf , chf earlier in the spring . we switched her from a furosemide to torsemide and symptomatically she is doing a lot better . she's about 3 , 3 and a half pounds down in weight . breathing is non-labored . going to repeat ekg today but otherwise continue with her current regimen . labs checked and creatinine is appropriate .
[doctor] uh number 2 , pre-op examination . she is , she's having a right knee replacement end of june . also , she would like to have a colonoscopy performed which we'll try to have done at uh bartley regional , rightley regional hospital in the next month , uh , prior to a change in her insurance . this is just a screening colonoscopy that she is overdue for . no family history of colon cancer .
[doctor] uh the next one is diabetes . a1c is 5.1 on the last check so no need for further a1c today . she may need another one prior to her surgery next month though . thanks .

CLINICAL NOTE

CHIEF COMPLAINT

Follow-up.

HISTORY OF PRESENT ILLNESS

Nicole Miller is a 71-year-old female who presents for follow-up. The patient was called in for a follow up with me for chronic congestive heart failure with diastolic dysfunction. Her BNP had been 3000 in 03/2021, up to 6000 in 04/2021. She was increasingly dyspneic. We had changed her furosemide to torsemide at 20 mg by mouth daily. The patient is not on a potassium supplement currently. Her lisinopril had also been increased up to 10 mg daily in 03/2021.

I last saw her in 04/2021, and she had reported being interested in having her right knee replaced this summer at East Metropolitan Hospital, so it was recommended that we work to control her cardiovascular status prior to surgery. She is currently scheduled to have surgery on 06/24/2021. She plans to discontinue clopidogrel a week before her surgery.

The patient states that she has lost approximately 3 to 3.5 pounds since her last visit in 04/2021. Some of which may be water weight decreasing. She did report experiencing bilateral leg cramps which she treated with consumption of pickle juice, which did resolve the cramps. She thought the cramps were related to her being cold.

She is still taking iron supplementation. She denies any concerns with defecation.

Regarding her prior symptoms of heartburn, she denies any recent gastrointestinal issues. She notes that her heartburn was severe at one point but resolved after trying Prilosec for 2 weeks in 01/2021. She denies any issues with heartburn since that time and has stopped taking Prilosec altogether. She has since transitioned back to her original "stomach medication".

The patient is due for a colonoscopy. She is currently double covered with Medicare and private insurance.

PAST HISTORY

Medical
Chronic Congestive Heart Failure.
Iron deficiency Anemia.

Medications
Prilosec.

FAMILY HISTORY

No family history of colon cancer.

CURRENT MEDICATIONS

Torsemide 20 mg by mouth daily.
Lisinopril 10 mg daily.

RESULTS

Magnesium 1.7, hemoglobin WNL, potassium 3.9, creatinine 0.7, BUN 23.
03/2020 Hgb A1c 5.5.

ASSESSMENT

 Chronic congestive heart failure with mixed presentation.
 Preop examination.
 Diabetes mellitus.
 Colonoscopy

PLAN

Chronic congestive heart failure with mixed presentation.
She had an exacerbation of CHF earlier in the spring. We switched her from furosemide to torsemide and symptomatically, she is doing a lot better. She is about 1.5 kg down in weight. Her breathing is nonlabored. We are going to repeat an EKG today. Otherwise, continue her current regimen. Labs were checked and creatinine is appropriate. Her magnesium is below the preferred 2 at 1.7, with some occurrence of bilateral leg cramping, therefore we will start her on magnesium supplement.

Preop examination.
She is going to be having a right knee replacement at the end of 06/2021. We will schedule a preop check the first week or two of June prior to the surgery. She will discontinue clopidogrel for one week prior to knee replacement surgery; we will provide a reminder to patient of this as well.

Diabetes mellitus.
A1c is 5.5 on last check, so there is no need for a further A1c today. She may need another one prior to her surgery next month.

Colonoscopy.
The patient is overdue for a colonoscopy, which we will try to have done at County Hospital in the next month, prior to a change in her insurance. This is just a screening colonoscopy that she is overdue for. No family history of colon cancer.

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

INSTRUCTIONS

Complete EKG today. Schedule a preop checkup 1st or 2nd week of June. Start magnesium supplement. Call the clinic with any questions or new symptoms.