Physician Assistant Prep Template

**John Doe** **DOB** 24/03/1978 **Last Visit** 15/09/2024 The patient was seen directly by the Physician Assistant. COPY: Dr. Sarah Chen (Cardiologist), Dr. Mark Johnson (PCP) **Dr. Carlson** Social history: Mr. Doe is a 46-year-old male, married, living with his wife and two children. He works as an accountant. He reports moderate alcohol consumption (2-3 drinks per week) and occasionally smokes cigars socially (less than 5 per month). He engages in light exercise (walking 30 minutes twice a week). Diagnosis List: 1. **Coronary Artery Disease** 2. Hypertension 3. Dyslipidemia 4. Type 2 Diabetes Mellitus LABORATORY FINDINGS: Echocardiogram: Ejection fraction 55%, mild mitral regurgitation, no wall motion abnormalities, left ventricular hypertrophy present (LVEDD 5.5 cm, LVESD 3.8 cm). Abdominal ultrasound: Normal liver and gallbladder, no renal abnormalities, abdominal aorta dimensions within normal limits (2.0 cm). Carotid Doppler: Left carotid artery 30% stenosis, right carotid artery 20% stenosis, no significant plaque noted, flow velocities within acceptable range. Pacemaker / AICD: Device is an AICD (Medtronic Evera XT DR) implanted in 2020. Battery status good (ERI at 7 years), lead impedance stable, sensing and pacing thresholds within normal limits. Holter or MCT: Holter monitor revealed occasional PVCs (total 50 in 24 hours), no sustained arrhythmias. Average heart rate 72 bpm, range 55-120 bpm. Ischemic testing: Exercise stress test performed. Achieved 10 METs, no EKG changes suggestive of ischemia, good perfusion results globally. Labs: **CBC** (WBC 7.2, Hgb 14.5, Plt 280), **CMP** (Na 138, K 4.1, Cr 0.9), **Lipid Panel** (Total Cholesterol 180 mg/dl, LDL 95 mg/dl, Triglycerides 140 mg/dl, HDL 45 mg/dl), **HbA1c** (6.8%). Follow up: Schedule follow-up echocardiogram in 6 months. Continue current medication regimen. Refer to cardiac rehabilitation program. Follow up with PA in 3 months. NOTE: Patient tolerating current medications well. Discussed importance of lifestyle modifications, including adherence to a low-sodium, low-fat diet and increasing physical activity. Patient expressed understanding and commitment to recommendations.