CHIEF COMPLAINT: Followup of abnormal labs, head congestion, and followup of Coumadin.
HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old Hispanic male. He is about a one-pack-per-day smoker, precontemplative with regard to smoking cessation. He has atrial fibrillation, status post valve replacement, on chronic Coumadin. He has had some compliancy issues in that he had previous failure to keep up with PT/INRs. He has had no chest pain, TIA symptoms or claudication. He has had no gross hematuria or other bleeding problems. He has had an MI, status post three-vessel bypass and aortic valve replacement, as well as stent.
He has diabetes but states he is not regularly checking his sugars. He is quite physically active. With regard to diabetic care, repeatedly we have recommended that he see an ophthalmologist, and he has not followed through on that yet. He had no polyuria, polydipsia, increased thirst, and no hyperglycemic episodes on his current treatments.
He has been compliant with Lipitor, taking it in the morning, and his medications include Glucotrol XL 10 mg b.i.d., Lipitor 40 mg a day, Coumadin 7.5 mg Tuesdays and Thursdays and 5 mg other days, metformin 2000 mg at night, Atrovent inhaler for COPD, and Diovan HCT 160/25 daily. He has had no foot problems. Foot screening in September was normal. No neuropathic pain, chest pain or TIA symptoms. He has had chronic head congestion with postnasal drainage without change. No fever or URI symptoms.
ALLERGIES: PENICILLIN.
SOCIAL HISTORY: The patient is one-half-to-one pack per day smoker and had quite a bit of chewing tobacco history in the past.
REVIEW OF SYSTEMS: Negative, except as stated in the subjective above.
PHYSICAL EXAMINATION:
VITAL SIGNS: Temperature 99.2, blood pressure 140/60, pulse 76, respirations 18, and weight 180.
GENERAL: The patient is alert and cooperative, in no distress.
HEENT: His conjunctivae are normal. No pallor. Head is atraumatic and normocephalic. External auditory canals normal. Visualized tympanic membranes normal. Nose had no exophytic lesions, discharge or active bleeding. Mouth showed no signs of oral infection. Tongue is midline. Floor of the mouth is normal. Oropharynx shows no lesions. Mucous membranes are moist.
NECK: Full range of motion. No thyromegaly or jugular venous distention.
LUNGS: Normal excursion. Chest is clear to auscultation. No consolidation.
HEART: Snapping second heart sound with a short aortic insufficiency murmur. Peripheral pulses diminished but palpable. Capillary refill about 3 seconds.
ABDOMEN: Soft, nondistended.
GENITOURINARY: Normal circumcised male. Testes without lesions. No hernia appreciated.
RECTAL: Normal tone. Positive hemorrhoid. Prostate is grade 3. No suspicious lesions. Large amount of stool in the vault, which is heme negative. No rectal masses.
EXTREMITIES: Onychomycosis in the feet. Some rubor consistent with PVD.
NEUROPSYCH: No change.
LABORATORY DATA: Stat PT/INR was obtained, which shows his INR to have dipped down to 1.40. His glycohemoglobin is 6.8%, acceptable. Microalbumin, he had greater than 300 mg/dL of protein and 5-10 red cells. His CBC showed H&H of 12.8 and 38.2 with slightly elevated white count and normal platelet count. His CMP showed a fasting glucose of 148. BUN was 32. Creatinine was 1. Remainder of CMP was normal. LDL was above goal at 106.
ASSESSMENT AND PLAN:
1. Microhematuria in a patient on chronic Coumadin with his tobacco abuse, rule out bladder carcinoma. Differential diagnosis was discussed with the patient, including benign causes. Renal ultrasound was ordered. We will set him up with Urology since he will probably have to have a cystoscope.
2. Chronic Coumadin therapy for valvular heart disease. The patient will adjust his Coumadin 7.5 mg Tuesdays, Thursdays, and Saturdays and recheck PT/INR first week of February.
3. Dyslipidemia. LDL is not at goal and blood pressure is above goal, which should be 130/80 or less. We will go ahead and switch him to Caduet 5/80 one at night and refill his Glucotrol and his other medications he gets. Five-week refills on his Coumadin. Urology evaluation after renal ultrasound. Flu vaccine was given and discharged in satisfactory condition.
