RG Clinic Note

HISTORY OF PRESENT ILLNESS: Mr. John Smith is a 68-year-old male with past medical history of hypertension, hyperlipidemia, and coronary artery disease (status post PCI in 2018). Mr. Smith presents to clinic today for a routine follow-up and evaluation of chest pain. Patient reports intermittent chest pain over the past month, occurring with moderate exertion. The pain is described as a pressure-like sensation, lasting approximately 5-10 minutes and is relieved with rest. He denies any shortness of breath, palpitations, or syncope. He reports adherence to his medication regimen and has not experienced any adverse effects. He states that he has been walking 30 minutes a day, 3 times a week. He denies any recent hospitalizations or emergency room visits. =============== CARDIOVASCULAR CONDITIONS: - Hypertension - Hyperlipidemia - Coronary Artery Disease (status post PCI 2018) - Atrial Fibrillation (CHADSVASC score 2, on Apixaban 5mg BID) - Heart Failure with preserved ejection fraction (HFpEF, EF 60%) CARDIOVASCULAR TESTING: - (08/15/2024) Stress test: Positive for ischemia in the inferior and lateral walls. - (09/20/2024) Cardiac Catheterization: showed 50% stenosis in the left circumflex artery. OTHER NON-CARDIAC CONDITIONS: - Type 2 Diabetes Mellitus - Osteoarthritis RELEVANT HOME MEDICATIONS: - Metoprolol 50mg daily - Lisinopril 20mg daily - Atorvastatin 40mg daily - Apixaban 5mg BID - Aspirin 81mg daily RELEVANT FAMILY AND SOCIAL HISTORY: - Lives at home with his wife. - Non-smoker, drinks alcohol occasionally. - Walks 30 minutes, 3 times a week. - No pets. - Diet is generally healthy. - Father had a history of coronary artery disease. =============== VITAL SIGNS: T 98.6, HR 72, RR 16, BP 130/80, SpO2 98% on room air. PHYSICAL EXAMINATION: - General: Well-appearing male in no acute distress - HEENT: Normocephalic, atraumatic; PERRLA - CV: Regular rate and rhythm; no murmurs, rubs, or gallops; no JVD - Pulm: Clear to auscultation bilaterally - Abd: Soft, non-tender, non-distended - Neuro: Alert and oriented x 3; CN II-XII intact - MSK: No lower extremity edema - Skin: Warm and dry TODAY'S ECG: Normal sinus rhythm with no significant ST-T wave changes. TODAY'S TTE: Left ventricular ejection fraction of 60%, mild mitral regurgitation. =============== ASSESSMENT: Mr. Smith presents with stable coronary artery disease and controlled hypertension and atrial fibrillation. His chest pain is likely related to his underlying coronary artery disease. The recent cardiac catheterization showed 50% stenosis in the left circumflex artery. His heart failure is well-controlled. SUMMARY OF RECOMMENDATIONS: - Continue current medications. - Increase Metoprolol to 75mg daily. - Schedule follow-up cardiac catheterization in 3 months. - Encourage patient to continue with regular exercise. - Discussed lifestyle modifications, including diet and exercise. - Schedule follow-up appointment in 3 months. Mr. John Smith will return to clinic in 3 months.