HPI: The patient is a pleasant 68 YOWM seen today to establsih care. He complains of intermittent shortness of breath which began about three weeks ago which is worse with exertion and is associated with bilateral lower extremity swelling.
REVIEW OF SYSTEMS: Complete ROS was obtained using a questionnaire, which I reviewed. Pertinent findings are as follows: CV: Negative for chest pain or PND, but positive for mild orthopnea. Pulm: Negative for cough or hemoptysis. Constitutional: Negative for unplanned weight loss or fevers. GI: Negative for N/V/D. For more details, please refer to the ROS quiestionnaire dated today located in this chart.
PFSH was obtained using a questionnaire. Pertinent findings are as follows: He has a known history of CAD and underwent CABG in 2003. The patient continues to smoke. Family history is strongly positive for CAD (father had MI at age 56). For more details, please refer to today's PFSH questionnarie located in this chart.
PHYSICAL EXAMINATION: GENERAL: NAD, conversant; looks older than stated age. BP 164/72, HR 84, RR 18. EYES: Anicteric sclerae; no lid lag; fundi clear, disc margins sharp. ENMT: Poor dentition, oropharynx clear with no pharyngeal erythema. NECK: FROM, supple, 2 cm JVD at 30 degrees; no thyromegaly. LUNGS: Bibasilar crackles, normal respiratory effort. CV: RRR, no MRGs. ABD: Soft, non-tender; no HSM. EXT: 2+ bipedal edema. SKIN: Warm, dry, well-perfused; no rash, lesions or livedo reticularis. PSYCH: A&OX3; appropriate affect.
LABORATORY INFORMATION: Shows a BUN 34, creatinine 1.2, Potassium 3.6, HGB 11.5, LDL 116.
IMPRESSION:
Acute, decompensated LV systolic failure
Stable CAD.
Poorly controlled HTN.
Relative dyslipidemai with a target LDL of 100.
PLAN:
Will send for echo report from previous cardiologist.
