SUBJECTIVE: This is an (XX)-year-old gentleman with a history of enterococcus UTI, recently hospitalized for a complicated UTI. The patient also has a history of CHF, EF of 35%, coronary artery disease, prostate cancer, hypertension and neurogenic bladder. Overall, since his discharge, he has been doing well. He is being seen by Wound Care Clinic for his left heel ulcer. No fevers, chills, chest pain, shortness of breath, nausea, vomiting, abdominal pain, lower extremity edema. Review of systems is otherwise negative. The patient has no known drug allergies. The patient has a past medical history of enterococcus UTI, resistant to Levaquin and amoxicillin, Charcot-Marie-Tooth disease with peripheral neuropathy and chronic pain, GERD, obstructive sleep apnea, CHF, ischemic cardiomyopathy with an EF of 35%, coronary artery disease with stents to the circumflex and LAD, TIA, prostate cancer, status post Lupron therapy, chronic renal insufficiency with baseline creatinine of 1.7 to 1.9, dyslipidemia, frequent UTIs with a chronic indwelling Foley, decubitus ulcer, left heel ulcer, neurogenic bladder, hypertension and history of pneumonia.
MEDICATIONS: Aspirin 81 mg p.o. daily, colchicine 0.6 mg p.o. daily on Mondays, Wednesdays and Fridays, digoxin 0.125 mg p.o. daily, Flomax 0.4 mg daily, Florinef 0.1 mg p.o. daily, Prilosec 20 mg daily, senna 1 tablet p.o. at bedtime, Marinol 2.5 mg p.o. q.a.m., Crestor 10 mg p.o. daily, Claritin 10 mg p.o. at bedtime, Ultram 25 mg p.o. t.i.d. p.r.n., metoprolol 25 mg p.o. b.i.d., Levaquin; he completed a full course of Levaquin and amoxicillin and recently completed a course of Keflex with last dose being today, Norvasc 5 mg p.o. daily.
OBJECTIVE: Weight 170 pounds. Blood pressure 140/60. Pulse 54. The patient is 100% on room air. He is a pleasant gentleman sitting in a wheelchair, in no acute distress. His oropharynx is clear. He has moist mucous membranes. Heart with regular rate and rhythm without murmurs, rubs or gallops. Chest is clear to auscultation bilaterally. Abdomen was soft and nontender with positive bowel sounds. Extremities were warm and well perfused. He has a foot boot on his left foot. He has no edema. Pulses are 1+ dorsalis pedis bilaterally. He is alert and oriented x3, answering questions appropriately.
The patient had a chest x-ray done this morning, which showed improvement in the pleural effusion and baseline atelectasis.
ASSESSMENT AND PLAN: This is an (XX)-year-old gentleman with a history of recent urinary tract infection and hospitalization, congestive heart failure, Charcot-Marie-Tooth disease with peripheral neuropathy and chronic pain, left heel ulcer and hypertension. The patient returns today in followup after his recent hospital admission.
1. History of recent urinary tract infection. The patient was advised that if his urine again becomes cloudy to immediately call Dr. John Doe. He has finished his courses of antibiotics and is otherwise doing well from this standpoint.
2. Heel ulcer. This is being followed by Wound Care Clinic.
3. Indwelling Foley catheter. He follows with Urology. See as above regarding advice if urine changes color, becomes cloudy or foul smelling.
4. Hypercholesterolemia. He continues his medications including Crestor.
5. Hypertension. He continues on the metoprolol. His blood pressure is doing well. He also is on Norvasc and doing well.
6. Pain in his feet. He is being given another prescription for Darvocet and he is currently on Ultram.
7. Congestive heart failure and ischemic cardiomyopathy. He should continue with the aspirin, digoxin, Crestor, metoprolol and Norvasc.
8. Followup: He will see Dr. Doe again next month. He already has an appointment scheduled. He will return if he has any other issues in the meantime.
