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CARDIOLOGY FOLLOWUP NOTE

 

DATE OF VISIT: XX/XX/XXXX

 

SUBJECTIVE:  This patient, who is XX years of age returns for cardiologic followup.  The patient has known coronary artery disease and had a coronary artery bypass in XXXX.  He underwent cardiac catheterization most recently at XXXX Medical Center in May XXXX and I coincidentally happened to be the attending for that procedure. At that time the patient was seen to have a patent LIMA to the LAD, the LAD being diffusely diseased.  The patient had had a patent SVG to OM.  The native circumflex system was dominant and supplied a PDA which had diffuse disease and was not bypassed. Left ventricular function was normal.  

 

The patient has undergone treadmill stress testing on XX/XX/XX here in the clinic and he exercised for 6 minutes achieving a heart rate of 117 beats per minute, blood pressure 166 systolic, and had chest pain and 0.5 mm of ST segment change.  It was felt that this was his stable status.  

 

The patient has nitroglycerin requiring angina about twice weekly.  He is a diabetic, hypertensive, hyperlipidemic, and continues to smoke.  He also has chronic renal failure.    

 

OBJECTIVE:  On physical examination the blood pressure is 138/74, pulse 75 and regular, and weight 200 pounds.  The chest is clear.  Heart PMI is not felt, S1 and S2 normal.  There is a grade 2/6 systolic murmur at the left sternal border.  There is no edema.     

 

ASSESSMENT:  The patient states his angina is stable.  Based on his last heart catheterization in XXXX in which diffuse disease was noted with normal left ventricular function, I feel as if it is most appropriate to maximize medical therapy. 

 

PLAN: 

1.       I will increase metoprolol to 100 mg per day. 

2.        I will have this patient return in followup to reassess him in 4 months with lipids, Chem-20, hemoglobin A1C and an EKG. 

Patient Name
Patient Medical Record Number
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