CHIEF COMPLAINT: The patient is here for reevaluation 3 months after his transient ischemic attack.
SUBJECTIVE: It has been 3 months since left arm clumsiness. He has made complete recovery with absolutely no residual. He denies any new symptoms. No headache, no double vision, facial numbness or tingling. He had no weakness in the arm or leg, no paresthesia, no other concerns.
He had been on Plavix, had bruising and discontinued, per neurologist back on aspirin. Similarly, bad muscle aching with simvastatin and discontinued same. Checking BP at home, numbers have been on target. No new symptoms or concerns at the present time.
MEDICATIONS: As per list, Actonel 150 mg monthly, amlodipine 2.5 mg, aspirin 81 mg, calcium plus D, thyroxin 50 mcg, metoprolol 25 mg 2 times a day.
ALLERGIES: None listed to medications.
SOCIAL HISTORY: Not smoking or taking significant alcohol.
OBJECTIVE: VITAL SIGNS: The patient’s weight is 207, up 5. Blood pressure is 132/82. Pulse is 72 beats per minute. Height is 70 inches. BMI 29.5. GENERAL: The patient appears well and comfortable. NECK: No bruit. LUNGS: Clear. No wheezing or rhonchi. HEART: Regular rhythm. No gallop or murmur. NEUROLOGIC: Cranial nerves II through XII, including visual fields, normal. Motor function is normal in both upper and lower extremities. DTRs are full and symmetric.
ASSESSMENT:
1. Transient ischemic attack, complete resolution. No further symptoms.
2. Hypertension, chronic control, on target.
3. Dyslipidemia, intolerant of statin medication.
4. Well care.
PLAN:
1. We have reviewed with the patient the possibility of recurrent symptoms, report any questions or concerns at once. Consider ER immediately if appropriate.
2. Continue with aspirin. Continue monitoring BP.
3. A 6-month update with exam and labs then. Earlier call as needed.
