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Clinical Note

Unstructured Clinical Text

Patient is a 64-year-old male presenting for follow-up after myocardial infarction 6 weeks ago. He underwent PCI with drug-eluting stent placement to the LAD. Patient reports he's been taking his medications as prescribed including metoprolol 50mg twice daily, lisinopril 10mg daily, atorvastatin 80mg at bedtime, and clopidogrel 75mg daily. He denies chest pain, shortness of breath, or palpitations. He has been walking 20 minutes daily as recommended by cardiac rehab. Blood pressure today is 128/78, heart rate 62 and regular. Cardiovascular exam shows regular rate and rhythm, no murmurs, rubs, or gallops. Lungs are clear bilaterally. No peripheral edema noted. Recent echo shows EF improved to 50% from 35% post-MI. Will continue current medications, increase lisinopril to 15mg daily for better BP control, and continue cardiac rehab program. Follow-up in 3 months with repeat lipid panel and basic metabolic panel.

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