[doctor] next patient is melissa sanchez . date of birth , 9/23/1962 . mrn : 5484367 . she is being seen in office today for status post mitral valve repair done on 8/3/2020 . at her previous follow-up on 9/17 , we felt that she was doing quite well from a cardiac standpoint , and so we recommended she continue with the same medication . ecg taken on 12/26/2020 reveals atrial fibrillation with a controlled ventricular response . t-wave inversion anteriorly . compared to the previous study , there are no significant changes , and please add in the history , patient has a history of mitral regurgitation and atrial fibrillation , history of diabetes , asthma , and recurrent chest discomfort with negative cardiac workup for coronary artery disease . [doctor] ms. sanchez , it's good to see you again . [patient] yeah , it's good seeing you too dr. hughes . you look like you're doing well . [doctor] i am , thank you . you too . you're looking great . how have you been feeling ? [patient] pretty good . i'm definitely feeling better , thank goodness . i was having a rough time before surgery , um , but i think i'm overall pretty good now though . [doctor] okay . well , that's really good to hear . i'm glad . are you having any new symptoms right now ? [patient] no , not really . but , you know , i'm still getting some chest pains sometimes , and my breathing gets shallow . but , i guess i'm learning what i can and ca n't do . uh , so if i feel like that , if i'm , like , exerting myself , i slow down a bit which helps , and then when i go back to it later , i can usually finish whatever i was doing . [doctor] okay . so , it does go away though ? how long does an episode seem to last ? [patient] uh , only a few minutes i guess . then it disappears for a while . it's weird . [doctor] what is a while ? [patient] it goes away for a couple weeks . um , so when it happens , i just take the day nice and slow , i do n't push myself . [doctor] okay . so , maybe it's a couple times a month you feel this way ? [patient] yeah , just often enough for me to notice . [doctor] understood . okay . are you taking your medications regularly ? [patient] uh- . i've been trying to keep up with that . there's a lot of extra pills now , but i have a reminder app , so i do pretty well . [doctor] okay . that's great . and so , you're taking coumadin , right ? [patient] yeah , also lasix and the atenolol . [doctor] are you having any side effects from the medications at all ? [patient] not really . uh , i notice that the atenolol is making me irritable in the beginning , but i guess i've gotten used to it , does n't seem to bother me as much now . [doctor] okay . well , that sounds good . sounds like you're well on the mend . so , why do n't i start out , um , with the physical exam , and just check you out . [patient] okay . [doctor] you're going to hear me describe things in detail or repeat things as i go to reference later for my notes . [patient] okay . [doctor] okay then . i'm going to be using my status post template , ms. sanchez , please lie down on the table here and we'll get started . all right . can you turn your head to the left . head and neck no jvd detected . you can turn back now and just take a couple of deep breaths for me please . okay , that's good . and lungs have reduced breath , but auscultation and percussion are clear . okay . breath normally , i'm just going to listen to your heart . rhythm is irregularly irregular . [patient] that's a funny statement . what does that mean ? [doctor] yeah , it does sounds kind of weird , right ? it's when your heart does n't beat with the correct rhythm , and whatever rhythm it does n't have a pattern to it . so , it's part of the atrial fibrillation . [patient] wow , that sounds like a mess . [doctor] yeah , it's not ideal . but , many people have a-fib are able to keep it under control with medicine and lifestyle changes . [patient] agh , i see . that's good to know . [doctor] okay . so , s1 slightly accentuated , no s3 . i'm going to touch your belly , and does any of that hurt . [patient] nope . [doctor] how about there ? and your feet ? [patient] no , not really . [doctor] okay , great . and trace peripheral edema on extremities . all right ms. sanchez , you can sit up now . so , it looks like your heart valves are working well and you are recovering from the surgery nicely . [patient] good . [doctor] yes . we are , we looked at your ecg taken earlier today , and we are seeing the a-fib , but it's being well controlled with the medicine , and you're taking coumadin , four milligrams , lasix at four milligrams a day , and the atenolol , you're taking that every day as well , right ? [patient] yes . the 50 milligrams every day . [doctor] great . it sounds like you're well on your way to recovery . [patient] great . [doctor] so , let's continue on your current meds . i'm glad that you're figuring out what your body can handle . definitely try to keep active as that will certainly help . [patient] i'll do my best . [doctor] and that's about it . do you have any questions for me ? [patient] um , i do . when do i need to come back and get checked out ? [doctor] well , i do n't think you need to come back soon . everything from a cardio perspective is fine . so , i think let's do a followup in about six to nine months . [patient] all right , thank you . it was good to see you again dr. hughes . [doctor] you as well ms. sanchez , do take care . [patient] you too .
ASSESSMENT

• Status post mitral valve repair
 
 Mrs. Melissa Sanchez is a 58-year-old female being seen today for a status post mitral valve repair, completed on 08/03/2020.

PLAN

Continue with current medications. Coumadin 4 mg daily, Lasix 40 mg daily, and Atenolol 50 mg daily.