An established office visit...

CC: F/U HTN

Interval History: The patient’s HTN remains stable on current medications. Hyperlipidemia is well controlled on statin therapy. CAD remains quiescent with no active chest pain.

ROS: Negative for orthopnea, PND, courh or hemoptysis

PFSH is remarkable for gout.

Exam: NAD. 128/76, 72, 20. Lungs are clear. Heart RRR. No peripheral edema

Chem 7 is WNL. LDL 68.

Impression

1. Stable HTN.
2. Well controlled hyperlipidemia.
3. Stable CAD.

Plan

1. Continue current medications.
2. We also discussed lifestyle and dietary modification.
3. RTC in four months with the usual labs.

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