SUBJECTIVE: The patient is an (XX)-year-old female known to me because of a history of likely underlying coronary artery disease, chronic obstructive pulmonary disease, aortic stenosis, mitral regurgitation and primary pulmonary hypertension. She returns in followup visit. The patient was seen by me last in May of last year, and since then, she has done fairly well from a cardiac standpoint. Of note, she remains quite frail and continues to be on hemodialysis 3 times a week. Reports worsening of her vision and no hospitalization for cardiac-related symptoms; however, was seen multiple times in the emergency room just about 3 weeks ago because of recurrent epistaxis, required treatment. She reports no chest pain at home or during dialysis. She is still limited by her dyspnea on exertion due to her underlying severe chronic obstructive pulmonary disease, overall unchanged from her baseline. No palpitation. No syncope or presyncope.
CURRENT MEDICATIONS:
1. Levothyroxine 0.05 mg daily.
2. Amiodarone 100 mg daily.
3. NephPlex Rx.
4. Amlodipine 10 mg half tablet daily.
5. Ecotrin 81 mg daily.
REVIEW OF SYSTEMS: Frail as above, limited functional capacity. Vision loss, apparently worsening. She denies orthopnea or PND or peripheral edema, but dyspnea on exertion persists. No syncope or presyncope.
OBJECTIVE: Vital Signs: The blood pressure here is 114/58 with a pulse of 66. The weight is 99 pounds, which is 6 pounds less compared to May of last year. HEENT/Neck: There is no visible JVD. The carotids are 2+, with a transmitted systolic murmur. Lungs: Have reduced breath sounds bilaterally, but they are clear to auscultation and percussion. Heart: Reveals a regular rate and rhythm with a systolic ejection murmur that radiates to the aortic area and a holosystolic murmur at the apex. No clear S3. Abdomen: Soft, nontender, nondistended. Extremities: Show 1+ edema.
DIAGNOSTIC DATA: Electrocardiogram revealed a normal sinus rate of 74 beats per minute with a septal infarct, mild IVCD, nonspecific ST-T changes. Compared to prior study in May, no significant changes.
The patient appeared to do well from a cardiac standpoint. Of note, she is an extremely frail lady getting by with her hemodialysis, unfortunately quite limited by the dyspnea on exertion. At this point, I would like to continue to monitor her on a clinical basis. Note, the patient has been advised by me to contact me promptly if there is any change in her well being. We did discuss at last followup the possibility of a pulmonary consultation; although, she is quite frail and would like not to travel a long way to see a specialist and noted that her dyspnea on exertion is overall unchanged. I think we can continue to follow on a clinical basis. Note as well that physical examination is overall unchanged. She will continue on the same medication. I will see her back in another 6 months.
ASSESSMENT:
1. Coronary artery disease, stable.
2. Aortic stenosis and mitral regurgitation.
3. End-stage renal disease.
4. Dyspnea on exertion.
5. Chronic obstructive pulmonary disease.
PLAN:
1. We will continue current medical regimen.
2. No need for further cardiac workup at the present time.
3. Return in another 6 months.
