This is a 69-year-old male with PMH of HTN, HDL
CC:
SUBJECTIVE:
S: This is a 69-year-old male with PMH of HTN, HDL, CVA/stroke in 2018 with a left-sided weakness and speech impairment presents to the clinic s/p hospitalization 10/15/24 to 10/23/24. Pt has Doppler evidence of Right lower limb artery occlusion in the superficial femoral artery. Patients complain of cramps in the right leg. 7/10 pain. The patient is still struggling with speech. He denies experiencing headaches, dizziness, blurry vision, shortness of breath, chest pain, or palpitations.
CT abdomen showed:- bilateral renal cysts measuring up to 6.8cm in the left upper pole.- enlarged prostate
– degenerative changes in L4-L5. He has 3 hours of home care,
MRI: Acute ischemic infarction involving Left cerebral hemispheric anterior, anterolateral, and posterior cortical border zones. Multiple old infarcts. No acute intracranial hemorrhage, ECHO: EF: 65-70 mg
Vital Signs:
Ht(without shoes)
165 cm (5’5”). Wt. (dressed) 77.11kg (170 lbs.) (BMI: 29.1 kg/m2) BP 132/88 mmHg (right arm seated); 135/89 mmHg (left arm, seated); with wide cuff. Heart rate (HR) 75 bpm and regular. Respiratory rate (RR) 18 bpm. Temperature (oral) 97.6°F, Spo2: 100% Room air.
make changes when necessary
Eyes;
Vision 20/20 in both eyes. Visual fields full by confrontation. Conjunctive pink; sclera white. Pupils 4 mm constricting to 2 mm. PERRLA. EOMI. Disc margins sharp, without hemorrhage, exudate. No arteriolar narrowing or A-V nicking.
Ears:
Ear canal clear bilaterally. TM clear bilaterally; bilaterally Ear good cone of light. The cone of light is at 5 o’clock in the right ear and 7 o’clock in the left ear. Rinne test: Positive bilaterally (AC > BC). Weber midline: No lateralization. Mastoid process: No tenderness noted bilaterally.
Nose
Mucosa pink, septum midline. No sinus tenderness. No polyps, turbinate intact, and there is no evidence of bleeding.
Mouth:
Oral mucosa pink. The dentition is good. Tongue midline. Tonsils 1+. Pharynx without exudates.
Neck:
Neck Supple. Trachea midline. Thyroid isthmus is palpable, lobes not felt.
Lymph Nodes:
No cervical, axillary, or epitrochlear nodes.
Thorax and Lungs:
Thorax Symmetric with good expansion. Lungs resonant on percussion. Breath sounds vesicular with no added sounds. Diaphragms descend 4 cm bilaterally.
Cardiovascular:
Regular rate and rhythm, heart rate 96 bpm. Crisp S1 and S2. At the base, S2 is louder than S1. At the apex, S1 is louder than S2. There are no murmurs or extra sounds.
-Musculoskeletal
Muscle or joint pain, stiffness, arthritis, gout, backache. If present, describe the location of affected joints or muscles, any swelling, redness, pain , tenderness, stiffness, weakness, or limitation of motion or activity; include timing of symptoms (e.g., morning or evening), duration, and any history of trauma. Neck or low back pain. Joint pain with systemic symptoms such as fever, chills, rash, anorexia, weight loss, or weakness.
Abdomen:
soft, non-tender + BS no guarding
Diagnostics:
Obtained before the diagnosis, examples: would be CBC or BMP, CXR or TSH etc.
Assessment:
Any diagnostics ordered/planned (this would be diagnostics needed)
· Pharmacologic and Nonpharmacologic: The patient was prescribed Polymyxin B/Trimethoprim solution one drop q 4 hours while awake
x7 days. (also enter quantity # here if controlled substance or antibiotics)
pharmacologic
Amlodipine besylate 10 mg tablet daily
Aspirin 81mg chewable tablet one tab daily
Clopidogrel 12.5 mg
Losartan 100 mg
Pantoprazole 10mg
Rosuvastatin 20 mg tab, one tab daily
Eliquis 2.5 mg tablet
follow up with Dr Nahata Vascular on 11/20/24 at Brookhaven.
RTC in 3 weeks pain assessment, might need pain management
·
Procedures: None at this time
·
Education:
non-pharmacologic
Referral:
NOTE
· Any diagnostics ordered/planned (this would be diagnostics needed)
· The patient was prescribed Polymyxin B/Trimethoprim solution one drop q 4 hours while awake
x7 days. (also enter quantity # here if controlled substance or antibiotics)
NO REFERENCE NEEDED
