[doctor] hey jose how are you doing it's been about you know three or four months since i last saw you what's going on
[patient] i'm doing okay i i guess the medications are helping i'm concerned about all the medications i'm taking but i think i'm doing okay
[doctor] yeah yeah you are on a fair amount of medications you know we do have you on those medications because you did have a heart attack about six months ago they put that that stent into your left anterior descending artery and so that's a major artery on the left side of your heart and so we need to keep those stents open and and kinda help your heart heal so it is gon na be very important for you to continue on those medications so you're still taking your aspirin and are you still taking the brilinta
[patient] yes and and fish oil
[doctor] and fish oil okay good now how are you doing with the crestor i know that that's you know that's the statin that's the cholesterol medication you were concerned that it might cause you to have some muscle aches are you taking that
[patient] i i think i'm doing good but i i am i feel like i i when i i guess the only complaint that i have is ever since i i do n't know if this is the heart attack or if this this is the the medication but when i stand up real fast i get really dizzy
[doctor] you get you get dizzy okay yeah you know we do have you on a what we call a beta-blocker metoprolol i think your dose is fifty milligrams once a day and you know sometimes it takes a little bit for your body to adjust to that but yes if you stand up too quickly it can cause you to be a little dizzy so
[patient] okay okay that makes sense okay that's good to know because i did n't know what what what the problem was so can i ask you a question regarding the stents
[doctor] yep
[patient] how long do i have to have that in there
[doctor] so the stents are permanent we do n't we do n't remove them so yep so that's why it's gon na be super important for you you know you're gon na be on aspirin for the rest of your life and then i'm gon na keep you on that brilinta for another six months that's gon na help prevent the that stent from clogging
[patient] okay okay do i need to ever replace the stents then
[doctor] no i mean every so often the stents can become narrowed again but you know that's why you're seeing me your cardiologist so that i can follow you for that now if you start to have symptoms again of any chest pain like you had before or any shortness of breath when you start to exert yourself i want you to tell me and we might have to go ahead and send you for further testing to make sure that those stents are okay but typically if you continue to take the medication watch your diet that type of thing your stents will will stay open for a long time
[patient] okay alright that sounds good you know i have n't i had a i had i know you asked me to follow up with the dietitian because i had diabetes as well which probably contributed to my heart attack
[doctor] yeah
[patient] i may need a new order i do n't i i forgot who i was supposed to talk to
[doctor] okay that's okay yeah i certainly can help you with that now managing your diabetes is also going to play an important role in your coronary artery disease which it sounds like you already know that which is really good so i will put in another referral for diabetic education for you how are you doing watching your sweets i know that you know you do have an afinity for those chocolate chip cookies
[patient] it's okay my a1c was n't where i wanted but my glucose is coming in in about one thirty
[doctor] okay
[patient] fasting
[doctor] okay what was the what was the a1c the hemoglobin a1c if you do n't mind me asking
[patient] i thought it was close to sixty
[doctor] okay yeah that's really high so we want it to be about six so you you do have some work to do with your diet
[patient] yeah yeah so okay so i know you asked me to do a blood test so i did that i was wondering if you got the results
[doctor] i did you know i looked at the results of your kidney function that's what we call your creatinine just because you had some contrast dye and sometimes contrast dye can impact the kidneys and your kidney function is stable which is great when was the last time you saw your nephrologist
[patient] oh
[doctor] that's your kidney doctor
[patient] i'm a bad i'm a bad patient so probably a year ago
[doctor] okay you know you do have the stage three ckd so that's the the stage three kidney disease so it is gon na be important for you to follow up with your nephrologist just to make sure that everything is okay now i did check your kidney function and and it was fine but are you staying away from things like motrin and advil
[patient] right yeah that's i threw all of those out
[doctor] okay good okay perfect now i know that you're from the west coast are you super excited that la one the super bowl or are you more of a san francisco forty nine or span
[patient] i'm a more of a san francisco fan
[doctor] so do you like jimmy g do you think he can beat erin rogers again
[patient] okay we'll see we'll see what happens but i'm pretty flexible when he comes to you know that is but one thing that since i ca n't take motrin what pain killer can i take for headaches
[doctor] you can take tylenol
[patient] okay
[doctor] yeah
[patient] alright that sounds good
[doctor] yeah
[patient] okay
[doctor] okay
[patient] this is i i do n't think i have any other question the only thing i'm gon na need is a i need some refills on my medications
[doctor] yeah i can do that but i do wan na just do a physical exam on you okay so and looking here at your vital signs here you know your your vital signs look quite good you know your blood pressure is what right where it should be it's about one twenty seven over eighty which is great so you're doing a good job taking your metoprolol now in terms of on your neck exam i do n't appreciate any jugular venous distention or carotid bruits on your heart exam i do appreciate a slight three out of six systolic ejection murmur heard at the left base and on your lower extremity exam i do appreciate some one plus nonpitting edema now what does that mean what does that mean jose so all of that means is that i do hear a little heart murmur on your heart which i've heard before in the past and it does n't it does n't look like you're retaining any fluid which is good but you do have a little puffiness in your legs which sometimes some of the medications can cause
[patient] yeah i do have that
[doctor] so let's just go over a little bit about my assessment and and plan for you going forward so for your first problem of your coronary artery disease i think you're doing really well i wan na go ahead and refer you for cardiac rehab just so that you can be more active and have some confidence in in exercising again okay and i am gon na go ahead and refill your metoprolol your crestor forty milligrams once a day as well as the aspirin okay i do n't think we need to proceed with a a stress test or anything at this time but you know to let me know if you have any symptoms okay
[patient] okay
[doctor] okay for your
[patient] sounds really good
[doctor] good for your second problem of your stage three chronic kidney disease i am gon na reach out to doctor miller and make an appointment for you to be seen just because again i think it's important for you to follow up with your nephrologist okay
[patient] okay
[doctor] and then for your third problem of your diabetes i am gon na go ahead and order another hemoglobin a1c and i'm gon na put that referral in for the dietitian to give you some dietary education and i'm gon na go ahead and talk with your primary care physician about your your insulin regimen okay
[patient] okay
[doctor] any questions
[patient] yeah you know i've been kinda down ever since i had my heart attack is there any medication that i could take to make me feel a little bit less sad
[doctor] yeah i mean are you having any thoughts of of harming yourself or harming others
[patient] no no i just feel kinda down
[doctor] you feel kinda down what's your
[patient] life sucks
[doctor] what well i do n't think so what what's your support system like
[patient] you know i i live with my dog and that's it so it's kind of you know lonely
[doctor] okay alright well would you be interested in in like a referral to psychiatry or something like that so that you have someone to talk to about some of of issues because medication can help but i do i think it's important to have you know talk some of these things out
[patient] okay yeah you know i'll give that a try i mean i'm retiring i got plenty of time
[doctor] okay so why do n't we go ahead and i'm gon na place a referral to psychiatry for you know you know difficulty adjusting after having a heart attack maybe some some mild depression okay does that sound okay okay
[patient] yeah that sounds really good thank you
[doctor] okay you're welcome anything else
[patient] so you will do the medication refill do i so that's automatic
[doctor] yep i'm gon na put them into the computer and and whatever pharmacy you want yep mm-hmm
[patient] okay alright sounds great thank you
[doctor] okay you're welcome i'll be in touch bye
[patient] okay alright bye-bye
CHIEF COMPLAINT

Follow-up.

MEDICAL HISTORY

Patient reports having a heart attack 6 months ago, coronary artery disease, diabetes.

SURGICAL HISTORY

Patient reports history of stent placement at the left anterior descending artery.

SOCIAL HISTORY

Patient reports that he is from the west coast and is a San Francisco 49ers fan. He lives with his dog.

MEDICATIONS

Patient reports taking aspirin, Brilinta, fish oil, Crestor, metoprolol 50 mg once a day,

REVIEW OF SYSTEMS

Musculoskeletal: Reports non-pitting lower extremity edema. Denies muscle aches.
Neurological: Reports dizziness and headaches.
Psychiatric: Reports depression. Denies suicidal ideation or homicidal ideation.

VITALS

Vital signs look good with blood pressure of 127/80.

PHYSICAL EXAM

Neck
- General Examination: No jugular venous distention or carotid bruits.

Respiratory
- Assessment of Respiratory Effort: Normal respiratory effort.
- Auscultation of Lungs: Clear bilaterally. No wheezes, rales, or rhonchi.

Cardiovascular
- Auscultation of Heart: Slight, 3/6 systolic ejection murmur heard at the left base.

Musculoskeletal
- Examination: 1+ non-pitting lower extremity edema.

RESULTS

Lab results are reviewed and show stable a creatinine level.

ASSESSMENT AND PLAN

1. Coronary artery disease.
- Medical Reasoning: The patient is doing very well and has been compliant with all medications. A slight 3/6 ejection murmur was heard on exam, however, this is stable and has been present in the past. He is experiencing 1+ non-pitting edema, but this seems to be medication related.

- Patient Education and Counseling: Patient was advised that his stents will remain in place permanently and that they typically do not require replacement. We discussed it is common to experience dizziness when standing quickly and that this should resolve once he is adjusted to his medications. We also discussed that cardiac rehab will be beneficial in helping him become more active and confident with exercising. He was advised to watch for symptoms such as chest pain or shortness of breath on exertion as this would need further testing such as a stress test.
- Medical Treatment: Referral to cardiac rehab was provided. A refill for metoprolol 50 mg once a day and Crestor 40 mg once a day was also provided. He is also advised to continue aspirin daily long term as well as Brilinta for the next 6 months.

2. Stage 3 chronic kidney disease.
- Medical Reasoning: Patient's most recent creatinine levels are stable.
- Patient Education and Counseling: We discussed the importance of following up with nephrology.
- Medical Treatment: He will follow up with his nephrologist, Dr. Miller.

3. Diabetes.
- Medical Reasoning: Patient reports most recent hemoglobin A1c was 16.
- Patient Education and Counseling: We discussed the importance of diabetes management and how plays an important role in his coronary artery disease. He was advised that his hemoglobin A1c goal will be 6.
- Medical Treatment: Repeat hemoglobin A1c was ordered today. A dietitian referral for diabetes education was also provided. We will contact his primary care physician regarding his insulin regimen.

4. Mild depression:
- Medical Reasoning: Patient reports feeling depressed and having a hard time adjusting since having his heart attack. He mentions he is also lonely and does not have a support system.
- Medical Treatment: Referral to psychiatry was provided today.

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