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Clinic Visit Note (3 months prior to hospital admission)

  • CC: "Elevated BP and increased shortness of breath"

  • HPI: Patient presents to the office to reassess changes to antihypertensive regimen. Based on home monitoring, his BP remains elevated with medication changes. Patient was previously instructed to make lifestyle changes related to the management of hypertension (HTN). He follows a low-salt diet and is trying to increase physical activity. His ability to exercise is limited by his shortness of breath.

  • PMH: CAD, HTN, COPD, DM

  • SH: Former heavy smoker (quit smoking 5 years ago), occasional alcohol use

  • ROS: Patient is in no acute distress, intermittent headache caused by sinus pressure

  • PE: Lungs are clear on auscultation, obese abdomen, no other notable findings

Current Home Meds

  • albuterol inhaler 1 inhalation q 4 hrs PRN SOB

  • aspirin 81 mg po daily

  • amlodipine 10 mg po daily

  • atorvastatin 40 mg po daily

  • lisinopril 40 mg po daily

  • metformin 1000 mg po bid

  • Nesina 25 mg po daily

  • Spiriva 18 mcg 1 capsule inhaled daily

Assessment/Plan

  1. HTN

    1. Start metoprolol 12.5 mg po bid

      1. Follow-up in 1 month to recheck BP

    2. Continue low-salt diet and exercise

  2. COPD

    1. Start budesonide/formoterol 160/4.2 mcg 1 puff BID

      1. Follow-up in 1 month to reevaluate COPD control

  3. DM

    1. Continue current medications

    2. Draw HbA1c today at clinic

      1. Follow-up in 1 month on A1c result when return for BP recheck

Dr. S. Florenz

Hospital Admission Note

  • CC: "Chest pain and shortness of breath"

  • HPI: Patient started to complain of chest pain and increased shortness of breath (SOB) while eating with his wife. He has been having chest pain and SOB off and on since his last doctor appointment and thought it may just be his COPD acting up again. He has been taking his albuterol inhaler every day and an extra puff of his new inhaler. This time his symptoms were much worse and his wife insisted that they call 911. EMS responded and transported the patient to the emergency department. The patient was given nitroglycerin 0.4 mg and morphine 4 mg during transport with little relief of chest pain. He has a long history of coronary artery disease (CAD) with prior percutaneous intervention (PCI) with stent placement in 2007.

  • PMH: CAD with right bundle-branch block, HTN, COPD

  • SH: Quit smoking 5 years ago, occasional alcohol consumption

  • FH: Father died from an MI at 45 years old, his mother died at 80 years old with no cardiovascular history. He has one living brother, 60 years old, who survived an MI at age 57.

Home Medications

  • albuterol inhaler 1 inhalation q 4 hrs PRN SOB

  • atorvastatin 20 mg po daily

  • metoprolol tartrate 25 mg po daily

  • amlodipine 10 mg po daily

  • Symbicort 160/4.5 MDI 1 ...

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