HPI: The patient is a pleasant 66 YOWM referred for pre-op consultation for surgical risk stratification prior to possible hip arthroplasty. He has a history of DM2 which has not yet required insulin as well as long standing HTN well controlled on the usual medications. There is also a history of hyperlipidemia for which he has been treated with statin therapy for approximately five years as well as CAD with a history of CABG back in the 1990s.
PFSH is remarkable for GERD as well as a remote history of tobacco abuse and a strong family history of premature cardiovascular disease.
Review of systems: Cardiovascular: no for chest pain or orthopnea. Pulmonary: no cough or hemoptysis. GI: no nausea, vomiting, bleeding. Musculoskeletal system is positive for severe, often disabling left hip pain. All other systems reviewed and are negative.
PHYSICAL EXAM shows a well-nourished white male who appears his stated age. Vital signs show a blood pressure of 140/90, heart rate of 82 and a respiratory rate of 22. Eye exam is normal. Cardiovascular: RRR, no MRGs with a normal PMI. Pulmonary: lungs CTA. GI: abdomen soft, non-tender with NABS and no HSM. Integumentary, neurologic and psychiatric systems are normal.
DATA: BUN 23, creatinine 0.9. HGB 12. HgbA1c 6.8. LFTs are normal. EKG was reviewed and showed NSR with normal axis and no ST changes.
I will send a copy of this note to Dr. Hayes with the following IMPRESSION and RECOMMENDATIONS:
The patient has severe osteoarthritis for which he is considering major surgery. His CAD, although presently stable, does place him at increased risk for postoperative mortality and morbidity. He also has multiple comorbidities including diabetes and HTN which also contribute to surgical risk and may hamper recovery. The patient was educated about the his increased surgical risk, but states that he does wish to proceed with surgery because his hip pain is currently causing a dramatic decrease in his quality of life. This being the case, I will order and echo for next week to quantify his systolic function. I also will start him on a beta blocker today. I further recommend that sliding scale insulin be substituted for his METFORMIN during his hospitalization.
