Report to Referring Doctor

01/11/2024 Dr. Eleanor Vance Consultant Cardiologist St. Jude's Hospital London, UK Dear Dr. Vance, Re: Mr. David Miller Date of birth: 12/03/1960 Diagnosis: * Hypertension * Hyperlipidaemia Presenting complaint and history: Mr. Miller presented today with a complaint of increasing shortness of breath over the past two weeks, especially on exertion. He denies chest pain or palpitations. He reports a history of hypertension, diagnosed five years ago, and hyperlipidaemia, diagnosed three years ago. He has been compliant with his medication regimen, including lisinopril 20mg daily and atorvastatin 40mg daily. He reports no recent changes to his medication or lifestyle. Relevant negatives: Denies chest pain, palpitations, dizziness, or syncope. No recent cough or fever. Past medical history: Hypertension, hyperlipidaemia, and a history of smoking (quit 10 years ago). On examination: General examination findings: Alert and oriented. Mildly overweight. Vital signs: Blood pressure 145/90 mmHg, heart rate 88 bpm, respiratory rate 18 breaths/min, SpO2 98% on room air. Systemic examination findings: Cardiovascular: Regular rhythm, no murmurs, rubs, or gallops. Lungs: Clear to auscultation bilaterally. No peripheral oedema. Pathology: Relevant pathology results: Lipid panel: LDL 3.5 mmol/L, HDL 1.2 mmol/L, triglycerides 1.8 mmol/L. Renal function tests within normal limits. Course and management: Discussed the importance of blood pressure control and lifestyle modifications. Continued current medication regimen. Advised regular exercise and a low-fat diet. Referred for a cardiology consultation. Additional investigations and findings: ECG showed normal sinus rhythm. Final diagnosis and outcome: Hypertension and hyperlipidaemia, stable but requiring further investigation of shortness of breath. Referred to cardiology for further assessment. With best regards, Dr. Thomas Kelly Internal Medicine Specialist