Cardiology Case Study 9

Cardiology

TAPE 8B, Report 9

CHART NOTE

The patient is status post MI and PTCA.  He takes Persantine
75 mg 3 times a day, Cardizem 60 mg 3 times a day.  Stopped taking his aspirin.  Has been having no chest pain, no shortness of breath.  Last week he developed some swelling in his left foot and his left leg, and it is quite painful.  This happened to him in the past as well.

On physical exam, his weight was 209, blood pressure 130/70, pulse rate 70, respiratory rate 18.  Chest clear.  Cardiovascular unremarkable.  Examination of the left lower extremity reveals there to be 1+ to 2+ pretibial and pedal edema.  Dorsalis pedis and posterior tibial pulses were obtained with the Doppler, both the left and the right.  There was a negative Homans sign.  No cords were palpable.

IMPRESSION

1. Coronary artery disease, status post myocardial infarction, status post percutaneous transluminal coronary angioplasty.

2. Venous insufficiency of the lower extremities.

3. Rule out gout, which I doubt.

4. Hypertension, presently adequately controlled.

RECOMMENDATIONS AND DISCUSSION

The patient can stop taking his Persantine, and we will taper him off the Cardizem, taking 60 mg b.i.d. for 3 days, 60 mg a day for 3 days, and then stop.  He will be given a fresh bottle of nitroglycerin if there is any breakthrough angina.  He is to call or return sooner p.r.n.  Was also started on Ecotrin 5 mg every other day.  Is to use his thigh-length TED hose on his left lower extremity and to keep the extremity higher than the heart when he is not up and about.  Is to have a blood pressure check in 1 week along with blood drawn for CBC, sodium, potassium, BUN, creatinine, uric acid, fasting blood sugar, and fasting lipid levels.  Return to clinic to see me in 1 month or p.r.n.

FOOTNOTE

Lines 22-27.  The abbreviations in the Impression are expanded for clarity.

Lines 22-27.  Enumerate the diagnoses in the Impression.