Outpatient Office Visit
Patient Case Number: OPOV68-Fogle, Tracey (new)
Patient Name: Tracey Fogle | DOB: 12-25-60 | Sex: F
Date of Service: 06-17-XX | Physician: Raymond Tiller, MD

# History of Present Illness: Pt is here to establish cardiac care-denies CP, SOB, c/o minimal edema in the feet. Mrs. Fogle has a known history of metabolic syndrome, morbid obesity, heart attack 2 years ago. Doing well no CP, has typical pseudoclaudication with edema in legs. Will recommend compression stockings. Pt was advised to lose weight.

# Medial History: Metabolic syndrome, CAD, Heart attack 2 years ago, hyperlipidemia, htn

# Allergy: Metoprolol

# Medications: Aspirin 81mg qd, Centrum daily, Fenofibrate 145mg-take 1 tablet every day, Indomethacin 50mg qd, Lisinopril 20mg qd, Simvastatin 40mg qd

# Surgical History: RCA Stent

# Review of Systems:

Patient reports no chest pressure, no lightheadedness, no chest pain, no dyspnea on exertion, no fatigue, no leg edema, no syncope, no orthopnea, no palpitations, no PND, and no shortness of breath.

Vitals:

Height | 5’0 ft
Weight | 205lbs
BMI | 40.0
BP | 128/60
Pulse | 72
Resp. | 17

Physical Examination:

Basic Cardio PE

HEENT: normal thyroid, no bruit, and JVP < 6.

Lungs: clear to auscultation.

Cardiac: no murmurs or gallops, S1 normal, S2 normal,

Abdomen: Non-tender or distended: no bruit, hepatomegaly, or, splenomegaly; and soft and normal bowel sounds.

Extremities: pulses 2+ and edema.

Assessment:

1. Metabolic syndrome

2. CAD

3. Old MI

4. Hyperlipidemia

5. Htn

6. Former smoker

7. Morbid obesity

# Electronically Signed By: Raymond Tiller, MD

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