[doctor] alright julia so you've been coming to see me for a while now ever since you had an rca stent placed back in twenty eighteen but i see you're here for follow-up after an interior stemi where we had to put in another stent right so like how are you doing
[patient] well i mean it was a real shock for me i thought everything was fine after my last heart attack and then i just started having this horrible chest pain and it would n't go away so i went to the emergency room and yeah they told me i needed another stent
[doctor] wow so you were experiencing similar symptoms similar to what you had the first time
[patient] yeah yeah it was yeah it was bad it was just like the last time
[doctor] okay have you had any chest pain or shortness of breath
[patient] no i think i saw you about six months ago and and i was doing fine
[doctor] okay have you been able to like exercise at all since since you last saw me
[patient] yeah you know i walk my dog everyday and you know we go like a mile and a half or two miles
[doctor] awesome okay yeah you know because like fall is setting in like are you excited
[patient] yeah yeah i'm excited
[doctor] do you have any like plans for the holiday
[patient] no mm-hmm no i'm just you know looking forward to seeing family and having some nice weather and yeah
[doctor] okay so i do wan na ask i know that you have a history of coronary artery disease hypertension and diabetes so i wan na get an idea of like where you stand with those have you been experiencing any kind of leg swelling
[patient] i have noticed that my legs are a little swollen since they sent me home from the hospital
[doctor] okay are you able to lie flat at night when you sleep
[patient] yeah i mean i always use a couple of pillows you know i maybe i've had to sit up a little bit more but i mean for the most part i think it's pretty normal
[doctor] okay and then have you been able to afford your medications and are you taking them like your like you were prescribed
[patient] yeah i'm able to afford afford them i have good insurance i am taking them they told me it's really important to take them so so yeah
[doctor] yeah that's very accurate you know like there are huge consequences to not taking them so if you are noticing any problems please please please please let us know how about your diet are you watching your salt intake
[patient] i mean i'm not i i i have n't really adjusted i mean i tried to watch it after the last heart attack and now you know i i've kind of been less strict with my diet but i'll have to go back to watching the salt intake
[doctor] mm-hmm
[patient] i love pizza it's my favorite food
[doctor] yeah
[patient] my tries are probably my second favorite food
[doctor] what are you for her toppings on pizza
[patient] pepperoni occasionally vegetables
[doctor] mm-hmm alright but you know that pepperoni is pretty high in salt on top of a cheesy pizza right
[patient] i know i know i'm gon na work on it
[doctor] okay so we are we are gon na have to negotiate some of these diet things and then especially since you have diabetes like have you been managing that well
[patient] my i've been watching my sugars yep because i do n't wan na go on insulin so i'm taking that metformin that's why i've been walking my dog i'm trying to stay active
[doctor] okay okay so you know maybe this is just a situation of like where we are on the right path but probably need to step up a few things okay
[patient] okay
[doctor] alright so i do want to do a quick physical exam so you are aware i'm going to be calling out my findings as i run through it alright
[patient] okay
[doctor] alright so your vital signs look good you know so i'm glad that it looks like you're tolerating your medication pretty well on your neck exam i do n't appreciate any jugular venous distention so and then on top of that i'm not i do n't appreciate any carotid bruits so i'm not feeling anything like too concerning on your heart exam though there is a three over six systolic ejection murmur heard at the that i'm hearing at the left base that's not like a huge deal especially considering like what you've been through already in terms of the hospital but it is something that i wan na know in your chart when i listen to you your lungs your lungs are clear over here with your extremities i do notice you know some lower lower edema swelling sorry some lower swelling edema lower limb edema and it it is pitting one plus on your right radial artery the cath site is clean dry and intact without hematoma and i also your right radial artery pulses are palpable so i did review the results of your ekg and they show a normal sinus rhythm and a good r wave progression and a a evolutionary changes that are anticipated after a stemi one of the reasons though that we had you come in is that we noticed on your echo there is a reduced ejection fraction of thirty five percent we are a little bit concerned about that so let's talk about my assessment and plan for you your primary and like first diagnosis is gon na be coronary artery disease right you already have a history of that but you know we're gon na do some things to make we're gon na continue to evaluate that over time i want you to continue your aspirin eighty one milligrams daily and your brilinta ninety milligrams twice daily i wan na continue you on a high dose statin called lipitor and you're gon na be taking that eighty milligrams a day and we're gon na continue you on your toprol and that's gon na be fifty milligrams daily i am gon na refer you to cardiac rehab so we can get you some education and give you some confidence to get back to exercising regularly i know it was kinda scary to have such an episode but i promise like most of the patients i have love cardiac rehab and i think you'll do pretty well for your second diagnosis we have newly you have newly reduced left ventricular dysfunction and moderate mitral regurgitation what i think is like what that means is that you're you're pumping like the way that your heart is pumping is a bit concerning but i think like given your history that it will improve over time they got you into the cath lab pretty quickly so i think that the muscle is just kinda like stunned like surprised and since you're compliant with your meds i think you will recover we are gon na continue you on your lisinopril twenty milligrams daily however considering that you are retaining fluid i think that your third diagnosis is like we are crossing into acute heart failure i'm gon na prescribe something called a diuretic it's called lasix and i do want to we need to take that forty milligrams once a day i wan na add aldactone twelve . five milligrams daily and i need you to get labs finally we will repeat another echo in about two months last but not least there is the hypertension your blood pressure seems fine i think with the aldactone that you'll tolerate that pretty well but we do want to maybe get you into some nutrition counseling to consider like what other diet options might be available to you maybe suggestions of things that you have n't thought about like cutting out meat especially any kind of preserved meat like pepperoni but maybe finding you some alternatives how does that sound
[patient] that sounds good yeah so i'm yeah as long as you tell me i'm gon na get better i believe you
[doctor] yes yeah i i strongly believe this is our best course of action and that you will get better given enough time i i see that you are making efforts i'm really glad that you are out there walking and that you're cognizant of your diet and willing to make changes we will just you know monitor it over time okay
[patient] okay
[doctor] alright thank you
CHIEF COMPLAINT

Follow up status post inferior STEMI.

SURGICAL HISTORY

RCA stent 2018

MEDICATIONS

aspirin 81 mg daily
Brilinta 90 mg twice daily
Lipitor 80 mg daily
Toprol 50 mg daily
lisinopril 20 mg daily
metformin

REVIEW OF SYSTEMS

Cardiovascular: Denies chest pain.
Respiratory: Denies shortness of breath.
Musculoskeletal: Reports bilateral leg swelling.

VITALS

Within normal limits

PHYSICAL EXAM

Neck
- General Examination: No jugular venous distention.

Respiratory
- Auscultation of Lungs: Clear bilaterally.

Cardiovascular
- Auscultation of Heart: No carotid bruits. A 3/6 systolic ejection murmur is heard at the left base.
- Examination: Right radial artery cath site is clean, dry, and intact without hematoma. Radial artery pulses are palpable.

Musculoskeletal
- Examination: Bilateral lower limb edema. Pitting 1+.

RESULTS

EKG is reviewed and demonstrates a normal sinus rhythm. Good R wave progression. Evolutionary changes that are anticipated after a STEMI.

Echocardiogram is reviewed and demonstrates a reduced ejection fraction of 35%.

ASSESSMENT AND PLAN

1. Coronary artery disease.
- Medical Reasoning: The patient has a history of coronary artery disease that we will continue to monitor.
- Medical Treatment: She will continue aspirin 81 mg daily and Brilinta 90 mg twice daily. She will continue Lipitor 80 mg a day and Toprol 50 mg daily. I am going to refer her to cardiac rehab for education and to gain confidence to resume exercising regularly.

2. Newly reduced left ventricular dysfunction and moderate mitral regurgitation.
- Medical Reasoning: A recent echocardiogram revealed a reduced ejection fraction of 35%. She was able to be treated in the cath lab in a timely manner, so I think that the muscle is just stunned. Given her history. it will improve over time.
- Patient Education and Counseling: I advised the patient that she will recover since she is compliant with her medications.
- Medical Treatment: Continue lisinopril 20 mg daily.

3. Acute heart failure.
- Medical Reasoning: The patient is retaining fluid.
- Medical Treatment: I am going to prescribe Lasix 40 mg once a day. I want to add Aldactone 12.5 mg daily. I will order lab work. We will obtain a repeat echo in approximately 2 months.

4. Hypertension.
- Medical Reasoning: Blood pressure is well controlled. She will tolerate the Aldactone well.
- Patient Education and Counseling: I encouraged the patient to continue exercising and to be cognizant of her diet. I explained that there are healthier alternatives available to reduce the amount of preserved meats she consumes.
- Medical Treatment: Continue lisinopril 20 mg daily. The patient received a referral to nutrition counseling to consider what other diet options might be available to her.

5. Type 2 diabetes.
- Medical Reasoning: Stable.
- Patient Education and Counseling: I encouraged the patient to continue monitoring her blood glucose levels.
- Medical Treatment: Continue metformin as prescribed.

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

INSTRUCTIONS

The patient will follow up as instructed.