ESL Cardio sample

HISTORY
This 30-year-old patient, with a history of inferior wall MI, post right coronary artery and circumflex stent, has been feeling well. No symptoms of chest pain. No symptoms of dyspnea, orthopnea, dizziness, lightheadedness. No syncope.

PHYSICAL EXAMINATION
Weighs 244 pounds. Blood pressure 120/82. Heart rate is 68, regular. HEENT: Pupils are equal. JVP is normal; no carotid bruit. Neck is soft, thyroid not enlarged, trachea midline. No cervical lymphadenopathy. Respiratory: Equal expansion, normal breath sounds. Heart: PMI in the 5th intercostal space. S1, S2 normal. No rub, no gallop, no murmurs. Abdomen soft, nontender. No bruits. Bowel sounds present. Extremities: Equal pulses. No leg edema.

ASSESSMENT
1. Coronary artery disease (CAD).
2. Left ventricular (LV) dysfunction.

PLAN
Increase Coreg to 25 mg b.i.d. Increase Vasotec to 20 mg daily. Continue with aspirin 325 mg daily, Plavix 25 mg daily. Return in 3 months.