Brooke's Clinic Template

HPI: 1 November 2024 Mr. John Smith, 68-year-old male, presents today for a follow-up on his peripheral artery disease (PAD) and assessment of leg pain. He reports worsening claudication in his left leg. Mr. Smith describes the onset of his leg pain as gradual, starting approximately 6 months ago. The pain is located in his left calf and is described as a cramping sensation. The duration of the pain is typically 10-15 minutes and is brought on by walking. The pain is relieved by rest. He rates the severity of the pain as 6/10. Mr. Smith is retired and walks for exercise 30 minutes daily. His diet is balanced, and he denies any limitations in his usual activities. Mr. Smith is a former smoker, having quit 10 years ago. He smoked one pack of cigarettes per day for 30 years. He is not currently interested in smoking cessation. Medications include: Aspirin 81mg daily, Atorvastatin 20mg daily, and Lisinopril 10mg daily. Imaging: Duplex Ultrasound of the lower extremities was performed. Performed at the local vascular lab. Date of imaging: 20 October 2024. Results showed significant stenosis in the left superficial femoral artery. ABI Results: R ABI result: 0.85 L ABI result: 0.60 R TBI result: 0.90 L TBI result: 0.65 Vascular History: * 2018 – Left Femoral-Popliteal Bypass – Dr. Emily Carter – City Hospital Assessment and Plan: 68-year-old male with peripheral artery disease (I73.9). Peripheral Artery Disease (I73.9) - Assessment: Worsening claudication in the left leg, consistent with progression of PAD. Reduced ABI in the left leg. - Plan: Continue Aspirin and Atorvastatin. Increase walking exercise to 45 minutes daily. Schedule follow-up duplex ultrasound in 6 months. Refer to vascular surgery for possible intervention. - Counseling: Discussed the importance of smoking cessation and lifestyle modifications. Short Summary: Mr. Smith presented for a follow-up on his PAD and reported worsening claudication. The plan includes continued medical management, lifestyle modifications, and referral to vascular surgery.