Patient Review For Doctors

HPI

is a 64 yo male w/ PMH of HTN, HLD, GERD, and previous coronary angioplasty in 2000 (artery unknown). Pt presented to his primary on 6/30/16 with CP. Pt stated that the pain has been occurring for a few months and that it began as non-exertional but currently occurs at rest. Pt states pain is located in his L chest, radiates down his L arm, lateral side, and jaw; he rates the pain as 4/10 in intensity. CT-Angiogram showed 90% stenosis in pt’s middle LAD. Over the course of approximately 3 months the pt’s pain increased in severity and frequency; less exertion was needed to trigger the pain, and a longer amount of time was needed to recover from the episode.

Vitals

BP:

Supine: 129/86 p:63
Standing: 133/82 p: 57

BMI: 27.6

Medication:

Pt’s medications prior to sx:

Anticoagulation: ASA 81 QD, Brilinta 90 BID,
HTN: Carvedilol 6.25mg BID, Diovan-HCTZ 160mg QD,
HLD: Lipitor 80mg QD
Pain: Nitro 400 Mcg spray .4mg/dose PRN

Presurgical optimization also included:

Brilliant / Ticegrelor 180 mg Qx1
Prednisone 40mg PO Q6 hrs for total of 4 doses
Solumedrol 40mg IV and Benadryl 25mg IV day of procedure

Soc Hx

Pt has a history of smoking 1/2 – 1 PPD x 14 years.

Studies

EKG: sinus brady, minimal ST elevations in Anterior Leads
ECHO:
- mild to moderate L Ventricle Hypertrophy
- Minimal LA dilation
- EF 60%
Coronary CT:
- LAD:
  - 70-80% stenosis in proximal LAD
  - 90-99% stenosis in middle LAD
- Diagonal 1: 25-49% stenosis
- R Circumflex: 1-24% (40% post sx) stenosis – proximal and distal
- Coronary Ca score: 25.9 (mild risk of MI),
- 32 Percentile
Carotid Duplex: non-obstructive dz bl –
- PSV were <125 and ICA:CCA was <3

Labs

Lipids:
- Elevated Tot Cholesterol, LDL, and Triglycerides: 232,152,168
Kidney:
- Elevated BUN and elevated BUN:Cr Ratio both of 26
- However GFR normal
CBC
- Possibly fighting infection:
  - Elevated WBC: 14.8
  - Elevated Absolute neutrophils: 10,301
  - Elevated Monocytes: 1258
- Elevated RDW: 15.1

Assessment & Plan

64 yo male w/ pmh of HTN, HLD, and Cardiac Cath in 2000 presented with exertional chest pain x 3 mo. His pain has progressively increased in severity, duration, and frequency. Pt’s CT Angiogram showed multiple stenosis the most severe being 90% stenosis in the middle LAD. Due to the pt’s elevated risk, aggressive treatment is required.

For today’s procedure we entered the coronary arteries via femoral vein. Stent was successfully placed in the proximal LAD. Prior to placement, ST elevation was noted in Lead II; upon placement decreased elevation was immediately noted. We then placed stent in the distal circumflex artery. Remaining blockages were noted in distal LAD, and R circumflex artery. Possible stent placement at distal LAD at later date. R circumflex is a large artery for this pt and as such mortality risks are greater. Pt is to make lifestyle changes to decrease his coronary and systemic atherosclerosis.

Pt is to return to clinic in 2 days for Post-Op Evaluation. Pt is will resume his regular medication schedule prior to sx including:

Anticoagulation: remain on ASA 81mg QD and Brilinta 90mg BID. Pt is high risk for ischemic occlusion and emboli due to remaining plaques and systemic atherosclerosis including BL Carotids.
HTN & HLD: Pt is to remain on Carvedilol, Diovan, and Lipitor; we will make medication changes as his diet, exercise, BMI, hypertension and hyperlipidemia improve.
Chest Pain: Pt is to continue taking Nitro 400 Mcg spray .4mg/dose PRN pain.

Pt is to contact our office for any concerns and proceed to the nearest ER if an emergent situation arises.

Uri M. Ben-Zur, M.D., F.A.C.C.
Interventional Cardiology / Invasive Electrophysiology

18200 Ventura Blvd
Tarzana, CA 91356
Phone (818) 986-0911 Fax (818) 986-9301
Date of visit: 07/05/2016
I had the opportunity to evaluate on the date stated above. I have reviewed the past medical history, symptoms and current therapy. In addition, I have examined the patient and based on my findings have provided my overall impression, outlining my treatment and plans in the summary below.

CHIEF COMPLAINT /HISTORY OF PRESENT ILLNESS:

COMPLEX PATIENT WITH MULTIPLE MEDICAL PROBLEMS. is an extremely pleasant 84 year old male with a past medical history of chronic ischemic cardiomyopathy with severe ventricular dysfunction, s/p CABG in 2006 and s/p ICD implantation in 2005, severe carotid artery disease, severe peripheral vascular disease s/p left carotid endarterectomy on 02/08/13. Other chronic comorbid conditions include hypertension, hyperlipidemia, diabetes mellitus, and a history of sustained ventricular tachycardia and sp ATP therapies. He is accompanied today by his grand-daughter, who provided translation and some of the history.

The patient presents today for a pre-procedure cardiac assessment. He is scheduled to undergo ICD pulse generator replacement/system revision at Providence Tarzana Medical Center on 07/13/16. This procedure has been scheduled given that his pulse generator is nearing ERI.

The patient is being followed closely given a history of complained of unsteady gait, dizziness, syncope, episodes of hypotension, and medical adjustments.

The patient’s granddaughter also reports that he has a history of intermittent left leg swelling. He was told to take Furosemide 10mg PO BID. The patient’s granddaughter increased the dose to 20mg PO BID given leg edema, and reports that it has improved.

The patient denies chest pain, palpitations. His blood sugar levels range from 110 to 150 mg/dL according to his granddaughter. is following an exercise program. He follows a low sodium diet.

The patient denies chest pain, palpitations His blood sugar levels range from 110 to 150 mg/dL according to his grandaughter. is following an exercise program. He follows a low sodium diet.

Overall, states that he is not feeling well.
PAST MEDICAL HISTORY:
Cardiovascular:
Carotid artery disease.
Congestive Heart Failure.
Coronary Artery Disease.
Hyperlipidemia.
Hypertensive heart disease.
Peripheral Vascular Disease.
Ischemic cardiomyopathy.
Genitourinary:
Benign Prostatic Hyperplasia.
Endocrine:
Diabetes mellitus.
SURGICAL HISTORY:
Cholecystectomy in 1996
Right inguinal hernia repair in 2004.
TURP in 2004.
Cataract surgery in 1994
S/P percutaneous coronary intervention and stent placement (2.25 x 12 mm Express) to the mid-LAD and distal LAD per Dr. Singh on 4/15/2005.
ICD implantation on 7/12/2005 due to severe LV dysfunction and progressive shortness of breath
Coronary Artery Bypass Grafting 09/07/2006 per Dr. Yasura at Northridge Hospital. (LIMA to the LAD, saphenous vein graft to the RCA and OM.)
Pacemaker pulse generator replacement 02/18/10
Cardiac cath 10/23/12
S/p left carotid endarterectomy on 02/08/13.

CURRENT MEDICATIONS:
1 Aspirin Ec 81 Mg Tablet SIG: 1 PO QOD alt with Clopidogrel
2 Clopidogrel 75 Mg Tablet SIG: 1 Tab QOD alt with Aspirin.
3 Glipizide Er 2.5 Mg Tablet SIG: take one tablet PO QD
4 Furosemide 20 Mg Tablet (Other MD) SIG: Take one tablet PO BID

ALLERGIES / INTOLERANCES:
Niacin, Cephalexin, Ranolazine, Pioglitazone

SOCIAL HISTORY:
Marital Status: The patient is married, with 4 children, one of whom has diabetes mellitus.
Smoking/tobacco use: No history of smoking.
Alcohol: The patient drinks alcoholic beverages. One glass of whiskey per month on average.
Recreational drug use: He denies recreational drug use.
Occupation: retired.

FAMILY HISTORY:
Father deceased. He died at the age of 87 due to myocardial infarction. H/o diabetes mellitus and multiple myocardial infarction. Age of 1st MI unclear.
REVIEW OF SYSTEMS:
Constitutional Symptoms: (-) fever, (-) chills, (-) night sweats, (-) fatigue, (-) weakness, (-) changes in appetite or weight.

Integumentary: (-) rash, (-) lumps, (-) itching, (-) dryness, (-) acne, (-) discoloration, (-) recurrent skin infections, (-) changes in hair, nails or moles.

Head: (-) headaches, (-) head injury or deformity, (-) visual changes, (-) eye pain, (-) double or blurred vision, (-) hearing changes, (-) tinnitus, (-) vertigo, (-) use of hearing aids, (-) frequent colds, (-) nasal allergies. Eyes: (-) visual changes, (-) eye pain, (-) eye discharge, (-) redness, (-) itching, (-) excessive tearing, (-) double or blurred vision, (-) glaucoma, (-) cataracts. Ears, Nose, Mouth, Throat: (-) hearing changes, (-) tinnitus, (-) vertigo, (-) dizziness, (-) earache, (-) ear infection, (-) ear discharge, (-) use of hearing aids. Neck: (-) swollen glands, (-) enlarged thyroid, (-) neck pain.

Respiratory: (-) cough, (-) hemoptysis, (-) cyanosis, (-) wheezing, (-) nocturnal choking or gasping.

Cardiovascular: (-) chest pain, (+) dizziness, (-) dyspnea with exertion, (+) edema, (-) irregular heartbeat, (-) orthopnea, (-) palpitations, (-) paroxysmal nocturnal dyspnea, (+) Syncope.
Cardiovascular: (+) dizziness, (+) edema, (+) Syncope.
Gastrointestinal: (-) abdominal pain, (-) heartburn, (-) constipation, (-) diarrhea, (-) nausea, (-) vomiting, (-) hematochezia, (-) melena, (-) change in bowel habits.

Genitourinary: (-) dysuria, (-) frequency, (-) urgency, (-) hesitancy, (-) polyuria, (-) nocturia, (-) hematuria, (-) urinary incontinence, (-) flank pain, (-) change in urinary habits.

Musculoskeletal: (-) muscle pain, (-) joint pain, (-) bone pain.

Peripheral Vascular: (-) intermittent claudication, (-) cramps, (-) varicose veins, (-) thrombophlebitis.

Neurological: (+) memory loss, poor balance.
Neurological: (+) memory loss, poor balance.
Endocrine: (-) heat or cold intolerance, (-) excessive sweating, (-) excessive thirst, (-) excessive hunger, (-) excessive urination, (-) hirsutism, (-) change in ring or shoe size.

Hematologic/Lymphatic: (-) anemia, (-) easy bruising, (-) excessive bleeding, (-) history of blood transfusions.

PHYSICAL EXAM:
Vitals:
BP: 131/63(Left Arm)(Standing)
Pulse: 66(Left brachial)(Supine)

Weight: 180 lbs
Height: 5′ 8″
BMI: 27.37
BSA: 1.98
BP: 164/70(Left Arm)(Sitting)
Pulse: 65(Left brachial)(Sitting)(Regular)
Respiration: 12

General Appearance: The patient is an extremely pleasant 84 year old male who looks younger than his stated age. is well developed and well nourished in no apparent distress. His body habitus is within normal limits, his mood is normal. Patient has cane assisted gait.
HEENT: Normocephalic and atraumatic. Pupils are equally round and reactive to light and accommodation. Extraocular muscles are intact. Patient’s neck is supple with no jugular venous distention, right carotid bruit was heard and carotid pulses are +2/2. Normal carotid artery upstroke bilaterally. Palpation is not painful and no thyromegaly nor lymphadenopathy can be appreciated.
Respiratory: Clear to auscultation bilaterally without wheezes or rhonchi. No intercostal retractions or accessory muscle use were noted.
Cardiovascular: Regular heart rate and rhythm. Cardiac point of maximal impulse at left fifth intercostal space mid-clavicular line. Normal S1, S2 with physiologic splitting of S2. III/VI systolic murmur. (+) S3 gallop. No thrills, rubs or clicks were heard. S/p sternotomy and ICD implant.
Gastroenterology: Abdomen is soft non-tender and non-distended. Positive bowel sounds, no hepatomegaly or splenomegaly was noted. No bruits were heard.
Extremities: Pulses were 2+ throughout bilaterally. No cyanosis or clubbing. 2+ left leg edema.
Musculoskeletal: Motor strength is appropriately intact throughout bilaterally.
Neurologic: Patient is alert and oriented x3 with deep tendon reflexes appropriately intact throughout bilaterally, non-focal.
Psychiatric: Patient is conscious, cooperative, and well-oriented to time, place, and person. There are no mood swings or psychotic features. Patient’s insight is good.
Skin: No skin rash, subcutaneous nodules, lesions or ulcers observed.
DIAGNOSTIC DATA:

ELECTROCARDIOGRAM: Date performed: Jul 5, 2016.
Indication: Recurrent shortness of breath.
Interpretation: Rate: 63 bpm; Rhythm: Non-specific ST-T changes, 1st degree AV Block PR=0.24ms, Apaced with capture, low voltage limb leads and ventricular pseudofusion, QRS = 0.11ms; Axis: Left axis deviation; Left Ventricular Hypertrophy.
Conclusion: Abnormal ECG.

2D COLOR DOPPLER ECHOCARDIOGRAPHY:
Date: Nov 3, 2015 Indication: Recurrent shortness of breath, H/O severe CAD s/p MI s/p CABG. H/O abnormal ekg, Dizziness. Follow up Pulmonary Pressures.
Technically very difficult study.

Findings:
Left atrium: Dimension: 4 cm. (Men: 3-4 cm/Women: 2.7-3.8 cm).
Left ventricle:
-LVIDd = 4.8 cm (Men:4.2-5.9 cm/Women: 3.9-5.3cm).
-LVIDs = 4.5 cm (2.0-4.1 cm).
-IVS = 0.8 cm (0.6-1.1 cm).
-LVPWd = 0.8 cm (0.6-1.1 cm).
Wall kinesis: Severe left ventricle dysfunction. Lateral, Inferior, and apical akinesis.

Right atrium: Normal in size and shape and shows no signs of ASD, mass or thrombus.
Right ventricle: RVSP: 48 mmHg (15-25 mmHg).
Pulmonary Artery: There is mild pulmonary hypertension.

Aortic valve: Peak Velocity = 1.4 m/sec (1.0 – 1.7 m/sec). No regurgitation. No sclerosis. No stenosis. Normal trileaflet aortic valve.
Mitral valve: Normal mitral valve without prolapse.
Tricuspid valve: Mild regurgitation. No sclerosis. No stenosis. No vegetations noted.
Pulmonic valve: Normal pulmonic valve.
Aorta: Ascending aorta: 2.9 cm. ( 2.1-3.4 cm).

Left ventricle ejection fraction: 35 %.

Pericardium: No effusion or calcification.
Venous: Inferior vena cava: Normal diameter with normal respiratory variation.

ICD INTERROGATION REPORT: Date of Interrogation: Jul 5, 2016.
Implant Indication:
Implant date: Feb 18, 2010.
Model: Medtronic Secura DR.
Battery status: 2.65 V. ERI: 2.63 V.
Estimated battery life: 0-2 months BATTERY NEARING DEPLETION.

Atrial sensitivity: 0.45 mV.
Atrial threshold: 0.5 V at 0.4 ms.
Atrial impedance: 551 Ohms.

Right Ventricular sensitivity: 0.3 mV.
Right Ventricular threshold: 0.875 V at 0.4 ms.
Right Ventricular impedance: 471 Ohms.

Atrial Pacing: 73 %.
Ventricular pacing: 20 %.
Mode switching episodes: 0.

Interrogation Assessment: Device function normal. 2 NSVT episodes, longest 2 seconds., BATTERY NEARING ERI.

DIAGNOSIS/ASSESSMENT:

HIGH RISK COMPLEX PATIENT. HE NEEDS CLOSE FOLLOW UP TO PREVENT RECURRENT HOSPITALIZATION.

CONGESTIVE HEART FAILURE, NYHA CLASS II-III. S3 (+)
AICD IN SITU.
Patient with marked limitation of activity, NYHA functional Class II-III, ACC/AHA Classification: Class C. S/P ICD implantation in 2005. S/p ICD implant on 7/12/05, ICD pulse generator replacement on 02/18/10. Today’s EKG revealed A paced with capture, non specific ST-T changes, 1st degree AV block, low voltage limb leads, ventricular pseudofusion, QRS 0.11 ms, left axis deviation, and LVH. Lateral, inferior and apical akinesis per echocardiography. EF 35%. BNP 6366 pg/mL on 05/19/16. Normal device function per interrogation today. The device is nearing ERI. He is scheduled to undergo pulse generator replacement at Providence Tarzana Medical Center on 07/13/16.The patient was advised of the importance of following a salt restricted healthy diet, weight loss and daily aerobic exercise. He was instructed to contact me or call 911, if his condition worsens.

PRE-PROCEDURE CARDIAC ASSESSMENT.
Pre-op evaluation: The patient is optimized from a cardiovascular standpoint for ICD pulse generator replacement at Providence Tarzana Medical Center on Jul 13, 2016. I had a long discussion with the patient regarding the risks, benefits, and alternatives of the procedure, including but not limited to infection, bleeding, heart attack, stroke, death, neurologic deficit, postoperative hematoma, postoperative pain, possible scarring/keloid formation. The patient was asked to repeat to me that anything can happen during a surgical procedure and that there is a possibility of death or severe disability as a result of the procedure. The patient and his granddaughter were able to do so without any difficulty. He is not a candidate for BIVD upgrade.

DIZZINESS/SYNCOPE/POOR BALANCE.
Likely medication related. Orthostatic changes on physical examination today. Recommend that the patient rise slowly from a lying down/seated position, and remain well hydrated at all times. He is to contact me or emergency services if this symptom worsens, or he develops new symptoms. Safety precautions and fall prevention discussed with the patient and his granddaughter. He was provided with a prescription for a walker.

CORONARY ARTERY DISEASE/ISCHEMIC CARDIOMYOPATHY.
History of myocardial infarction, S/p percutaneous coronary intervention on 4/15/2005. S/p Coronary Artery Bypass Grafting at Northridge Hospital on 09/07/2006. Low likelihood of jeopardized myocardium per nuclear cardiac imaging on 11/20/14. Continue Aspirin and Plavix. I discussed therapeutic options available to him, including further evaluation by Dr. Mark L. Barr, M.D., of Cardiothoracic Surgery, USC for possible heart transplant. He declines.

H/O PAROXYSMAL SUSTAINED / NON-SUSTAINED VENTRICULAR TACHYCARDIA.
The patient was advised to avoid alcohol, caffeine, and other stimulants which may precipitate his condition. Will monitor closely with serial device interrogation.

H/O CAROTID ARTERY DISEASE.
S/p post left carotid endarterectomy on 02/08/13. Non-obstructive disease per carotid artery duplex scan. Recommend follow-up with Dr. Nassoura.

HYPERTENSION.
No evidence of renal artery stenosis/abdominal aorta aneurysm/LVH on diagnostic studies. Continue Furosemide. The patient was advised to monitor his blood pressure twice daily and provide me with the records. Target systolic blood pressure in the 110-120 mmHg range recommended. Low sodium diet advised.

HYPERLIPIDEMIA.
LDL 93 mg/dL, HDL 72 mg/dL on 05/19/16. Low fat, healthy diet advised. Defer management to Dr. Flora.

DIABETES MELLITUS TYPE II.
Hb A1c 8.9% per labs on 05/19/16. The patient is on Glipizide. Low carbohydrate diet advised. Defer management to Dr. Flora.

LEG EDEMA.
Actos was discontinued. Recommend that the patient raise his lower extremities above heart level for 30 minutes, 3-4 times daily and follow a low salt diet. He may benefit from the use of TED stockings.

OTHER:
– Incidental finding of right complex thyroid nodule on ultrasound performed on 05/12/08. Followed by Dr. Nourparvar.
– History of benign prostate hyperplasia, S/p TURP in 2004. Defer management to Dr. Flora.
– Renal insufficiency, BUN 39 mg/dL and Cr. 1.65 mg/dL, eGFR 38 on 06/21/16. Will follow with serial labs.
– Memory loss. Defer management to his internist.
– Anemia. Possibly related to renal insufficiency. Defer management to his internist.

DISCUSSION:
s medical problems were explained to him in detail.

PLAN:
Pre-op evaluation: The patient is optimized from a cardiovascular standpoint for ICD pulse generator replacement at Providence Tarzana Medical Center on Jul 13, 2016. I had a long discussion with the patient regarding the risks, benefits, and alternatives of the procedure, including but not limited to infection, bleeding, heart attack, stroke, death, neurologic deficit, postoperative hematoma, postoperative pain, possible scarring/keloid formation, reoperation, need for emergent operation, possible blood transfusion and its complications, complications associated with anesthesia, and possible drug allergies. The patient was asked to repeat to me that anything can happen during a surgical procedure and that there is a possibility of death or severe disability as a result of the procedure. The patient was able to do so without any difficulty.
Medication changes: No.

Diet: Patient advised to follow a healthy low fat, salt and carbohydrate diet.

Exercise recommendations: Regular exercise is strongly recommended.

Hypertension Instructions: The patient was instructed to monitor their blood pressure twice daily and provide me with the records.

Diabetes recommendations: Patient was instructed to receive
A. Dilated retinal eye exam with interpretation by an ophthalmologist.
B. Urine screening for micro-albumin/evaluation by a nephrologist.
C. Foot examination (includes visual inspection, sensory exam with monofilament and pulse exam) by the patient’s primary physician.
D. Diabetes management is being deferred to the patient’s internist or endocrinologist.

Anxiety recommendations: The patient was advised to practice stress reduction techniques, including but not limited to meditation, deep breathing, yoga and exercise as tolerated.

Preventive Medicine: It is important that the patient follow up with their primary physician for preventative medicine follow ups including yearly prostate exam and annual physical exam.

Internal Medicine Care: The patient was notified that I do not practice general internal medicine. Routine examinations such as breast, prostate, and colonoscopy examinations as well as other internal medicine issues, including but not limited to, routine blood tests and routine medical examinations, shall be performed by the patient’s internist.

Follow Up: The patient was advised to return to the office for follow up in 3 days or earlier if he has any medical problems.

Emergency recommendations: The patient was advised to call 911 or go to the emergency room if the patient’s condition worsens or does not improve.

URI BENZUR, M.D., F.A.C.C.
Fellow, American College of Cardiology.
Diplomate, American Board of Internal Medicine, Internal Medicine.
Diplomate, American Board of Internal Medicine, Cardiovascular Disease.

This document contains protected and privileged, highly confidential medical, Personal and Health Information (PHI) and/or legal information. The information is intended only for the use of the individual or entity named above. If you have received this document in error please contact the office immediately.

Uri M. Ben-Zur, M.D., F.A.C.C.
Interventional Cardiology / Invasive Electrophysiology

18200 Ventura Blvd
Tarzana, CA 91356
Phone (818) 986-0911 Fax (818) 986-9301
Date of visit: 07/06/2016
Reason for Visit:
Requesting Physician:
I had the opportunity to evaluate on the date stated above. I have reviewed the past medical history, symptoms and current therapy. In addition, I have examined the patient and based on my findings have provided my overall impression, outlining my treatment and plans in the summary below.

CHIEF COMPLAINT /HISTORY OF PRESENT ILLNESS:

is an extremely pleasant 69 year old female with a past medical history of mitral valve prolapse s/p metallic mitral valve replacement, paroxysmal atrial fibrillation, and mild-moderate ventricular dysfunction.

The patient is being seen frequently given labile INR’s. The patient presents today for anticoagulation surveillance.

The patient denies chest pain, shortness of breath, palpitations, dizziness, or syncope of late.

Her blood pressure has been controlled with current therapy according to her home monitor. Ms. SCHREIBER is following an exercise program. She follows a healthy diet.

At the time of her last visit, no medication changes were made.

Overal states that she is stable.
PAST MEDICAL HISTORY:
Cardiovascular:
Paroxysmal Atrial Fibrillation.
Hypertension, benign essential.
Mitral Valve Prolapse s/p Mitral valve replacement Metallic Model # 33MECJ-0502 St. Jude Device; UCLA Harbor.
Neurology:
Transient Ischemic Attack, 04/2011. Henry Mayo Clinic.
SURGICAL HISTORY:
S/p Mitral valve replacement Metallic Model # 33MECJ-0502 St. Jude Device, UCLA Harbor
Hysterectomy
Cataract surgery, OU (OD 2007/OS 2011)
Tooth extraction. 08/15/15.

CURRENT MEDICATIONS:
1 Metoprolol Succinate 50 Mg Tablet Extended Release 24 Hr SIG: Take 1 PO TID
2 Coumadin 1 Mg Tablet SIG: 4/4/5 mg alt PO QD.

ALLERGIES / INTOLERANCES:
aspirin, Penicillins, Sulfa (Sulfonamide Antibiotics), Quinolones

SOCIAL HISTORY:
Marital Status: The patient is single.
Members of Household: She lives alone.
Smoking/tobacco use: No history of smoking.
Alcohol: Non-alcoholic beverage drinker.
Recreational drug use: She denies recreational drug use.
Diet: No diet restrictions.
Caffeine Intake: Drinks coffee occasionally.
Stress Level: High.
Occupation: Currently unemployed.

FAMILY HISTORY:
The patient’s father is deceased. He died at the age of 81. Cause of death unknown.
The patient’s mother is deceased. She died at the age of 56 due to due to complications of diabetes.
REVIEW OF SYSTEMS:
Constitutional Symptoms: (-) fever, (-) chills, (-) night sweats, (-) fatigue, (-) weakness, (-) changes in appetite or weight.

Integumentary: (-) rash, (-) lumps, (-) itching, (-) dryness, (-) acne, (-) discoloration, (-) recurrent skin infections, (-) changes in hair, nails or moles.

Head: (-) headaches, (-) head injury or deformity, (-) visual changes, (-) eye pain, (-) double or blurred vision, (-) hearing changes, (-) tinnitus, (-) vertigo, (-) use of hearing aids, (-) frequent colds, (-) nasal allergies. Ears, Nose, Mouth, Throat: (-) hearing changes, (-) tinnitus, (-) vertigo, (-) dizziness, (-) earache, (-) ear infection, (-) ear discharge, (-) use of hearing aids. Neck: (-) swollen glands, (-) enlarged thyroid, (-) neck pain.

Respiratory: (-) cough, (-) hemoptysis, (-) cyanosis, (-) wheezing, (-) nocturnal choking or gasping.

Cardiovascular: (-) chest pain, (-) edema, (-) high blood pressure, (-) irregular heartbeat, (-) orthopnea, (-) palpitations, (-) paroxysmal nocturnal dyspnea, (-) shortness of breath.

Gastrointestinal: (-) abdominal pain, (-) heartburn, (-) constipation, (-) diarrhea, (-) nausea, (-) vomiting, (-) hematochezia, (-) melena, (-) change in bowel habits.

Genitourinary: (-) dysuria, (-) frequency, (-) urgency, (-) hesitancy, (-) polyuria, (-) nocturia, (-) hematuria, (-) urinary incontinence, (-) flank pain, (-) change in urinary habits. Genito-Reproductive: (-) genital sores or lesions, (-) history of STD, (-) sexual difficulties.

Musculoskeletal: (-) muscle pain, (-) joint pain, (-) bone pain.

Peripheral Vascular: (-) intermittent claudication, (-) cramps, (-) varicose veins, (-) thrombophlebitis.

Neurological: (-) numbness, (-) tingling, (-) tremors, (-) seizures, (-) vertigo, (-) memory loss, (-) any focal or diffuse neurological deficits.

Endocrine: (-) heat or cold intolerance, (-) excessive sweating, (-) excessive thirst, (-) excessive hunger, (-) excessive urination, (-) hirsutism, (-) change in ring or shoe size.

Hematologic/Lymphatic: (-) anemia, (-) easy bruising, (-) excessive bleeding, (-) history of blood transfusions.

PHYSICAL EXAM:
Vitals:
Weight: 79 lbs
Height: 5′ 7″
BMI: 18.79
BSA: 1.60
BP: 121/63(Left Arm)(Sitting)
Pulse: 74(Left brachial)(Sitting)(Regular)

General Appearance: The patient is an extremely pleasant 69 year old female who looks younger than her stated age. is well developed and well nourished in no apparent distress. Her body habitus is within normal limits, her mood is normal.
HEENT: Normocephalic and atraumatic. Pupils are equally round and reactive to light and accommodation. Extraocular muscles are intact. Patient’s neck is supple with no jugular venous distention, no carotid bruits were heard and carotid pulses are +2/2. Normal carotid artery upstroke bilaterally. Palpation is not painful and no thyromegaly nor lymphadenopathy can be appreciated.
Respiratory: Clear to auscultation bilaterally without wheezes or rhonchi. No intercostal retractions or accessory muscle use were noted.
Cardiovascular: Cardiac point of maximal impulse at left fifth intercostal space mid-clavicular line. Normal S1, S2 with physiologic splitting of S2. Mitral valve click heard. No murmurs, thrills, rubs, or gallops were heard. Sternotomy scar healed well.
Gastroenterology: Abdomen is soft non-tender and non-distended. Positive bowel sounds, no hepatomegaly or splenomegaly was noted. No bruits were heard.
Extremities: Pulses were 2+ throughout bilaterally. No cyanosis, edema or clubbing.
Musculoskeletal: Motor strength is appropriately intact throughout bilaterally.
Neurologic: Patient is alert and oriented x3 with deep tendon reflexes appropriately intact throughout bilaterally, non-focal.
Psychiatric: Patient is conscious, cooperative, and well-oriented to time, place, and person. There are no mood swings or psychotic features. Patient’s insight is good. Memory and judgement are intact.
Skin: No skin rash, subcutaneous nodules, lesions or ulcers observed.
DIAGNOSTIC DATA:

Encounter long term anticoagulant. Date: Jul 6, 2016.
INR: 2.2.
Current Dose: : 4/4/4/5mg PO QD alternating dose.
Therapeutic Goal/INR: 2.5 – 3.5.
Medication adjustments: Continue same Coumadin dose.

Chest X-ray:
TECHNIQUE: Chest X-ray is PA/Lat view.
FINDINGS: The heart size is at the upper limits of normal in size. Median sternotomy sutures and a mitral valvular prosthesis are present. There is a mild linear scarring in the right perihilar region. No acute infiltrates are present. Aeration is improved at the lung bases compared to the prior study (07/08/13). The bony thorax is intact.
IMPRESSION: No acute disease, improved aeration at the lung bases.

ELECTROCARDIOGRAM: Date performed: Aug 16, 2015.
Indication: History of Rheumatic heart disease. H/o severe valvular heart disease, S/p MVR, occasional shortness of breath.
Interpretation: Rate: 68 bpm; Rhythm: Normal sinus rhythm, PRWP, IVCD and non-specific ST-T changes.
Conclusion: Abnormal ECG.

2D COLOR DOPPLER ECHOCARDIOGRAPHY:
Date: Aug 16, 2015 Indication: Occasional shortness of breath, Abnormal EKG, h/o severe valvular disease s/p Mitral Valve repair, Patient wished to be seen immediately.

Findings:
Left atrium: Dimension: 4.9 cm. (Men: 3-4 cm/Women: 2.7-3.8 cm). It is moderately dilated.
Left ventricle:
-LVIDd = 3.9 cm (Men:4.2-5.9 cm/Women: 3.9-5.3cm).
-LVIDs = 2.3 cm (2.0-4.1 cm).
-IVS = 1 cm (0.6-1.1 cm).
-LVPWd = 0.8 cm (0.6-1.1 cm).

Right atrium: Normal in size and shape and shows no signs of ASD, mass or thrombus.
Right ventricle: RVSP: 37 mmHg (15-25 mmHg). Increased right ventricular pressure.

Aortic valve: Peak Velocity = 2 m/sec (1.0 – 1.7 m/sec). Normal trileaflet aortic valve.
Mitral valve: Doppler Area is 2.5 sq cm by Doppler pressure half-time (0.6 – 1.3 m/sec). S/p MVR.
Tricuspid valve: Normal tricuspid valve.
Pulmonic valve: Normal pulmonic valve.
Aorta: Ascending aorta: 2.7 cm. ( 2.1-3.4 cm).

Left ventricle ejection fraction: 50 %. PSM.

Pericardium: No effusion or calcification.

CAROTID ARTERY DUPLEX SCAN:
Date of Study: Aug 15, 2014.
Indication: Right hand numbness.

Measurements:
Left:
CCA distal peak velocity: 88 cm/sec.
CCA end diastolic velocity: 23 cm/sec.
ICA distal peak velocity: 66 cm/sec.
ICA end diastolic velocity: 26 cm/sec.
ECA distal peak velocity: 73 cm/sec.
ECA end diastolic velocity: 23 cm/sec.
Left vertebral artery showed antegrade flow.
ICA/CCA: 0.8.
Right:
CCA distal peak velocity: 66 cm/sec.
CCA end diastolic velocity: 23 cm/sec.
ICA distal peak velocity: 76 cm/sec.
ICA end diastolic velocity: 24 cm/sec.
ECA distal peak velocity: 89 cm/sec.
ECA end diastolic velocity: 18 cm/sec.
Right vertebral artery showed antegrade flow.
ICA/CCA: 1.2.

Impression/Comments:
Left:
Left bulb plaque: less than 10%.
Right:
Right bulb plaque: less than 10%.

Plan:
Non-obstructive disease.
Will intensify medical therapy.

LOWER EXTREMITIES VENOUS DOPPLER: Sep 13, 2011.
Indication: shortness of breath, trace to 1+ bilateral leg edema.
Impression: Normal venous flow with normal collapse with compression. Normal augmentation of venous flow with calf compression. No evidence of venous insufficiency with valsalva manuever or abdominal pressure. Normal lower extremities.
No evidence of deep venous thrombosis or venous outflow obstruction of the lower extremities by duplex scanning.

RENAL ARTERY-AORTA DUPLEX SCAN: Sep 27, 2011.
Indication: Hypertension (401.1).

Measurements:
Left Renal Peak Systolic Velocity:
Proximal: 0.61 m/s [<1.0].
Mid: 0.39 m/s [<1.0].
Distal: 0.48 m/s [<1.0].
Renal/Aortic Ratio: 0.7. [<3.5].
Right Renal Peak Systolic Velocity:
Proximal: 0.44 m/s [<1.0].
Mid: 0.28 m/s [<1.0].
Distal: 0.57 m/s [<1.0].
Renal/Aortic Ratio: 0.7. [<3.5].

Aorta:
Proximal Aortic Diameter: 1.8 cm.
Mid Aortic Diameter: 1.5 cm.
Distal Aortic Diameter: 1 cm.
Aortic Peak Systolic Velocity: 0.86 m/s.

Kidney:
Left:
kidney length: 8.8 cm [8.5-15.0 cm].
Kidney Width: 4.1 cm. ( 4.5-5.0 cm].
Kidney Depth (trans): 4 cm. [4.5-5.0].
Cortical Thickness: 1.4 cm. [1.1 cm].
Parenchymal Flow /Waveform:
Upper Early Systolic Peak Present.
Mid Early Systolic Peak Present.
Lower Early Systolic Peak Present.
Resistive Index: 0.71 [<0.75] (PSV-EDV/PSV).

Right:
kidney length: 8.4 cm [8.5-15.0 cm].
Kidney Width: 3.5 cm. ( 4.5-5.0 cm].
Kidney Depth (trans): 4.6 cm. [4.5-5.0].
Cortical Thickness: 1 cm. [1.1 cm].
Parenchymal Flow /Waveform:
Upper Early Systolic Peak Present.
Mid Early Systolic Peak Present.
Lower Early Systolic Peak Present.
Resistive Index: 0.73 [<0.75]
(PSV-EDV/PSV).

Technical impression:
Within normal limits.
Mild plaque seen in abdominal aorta.

ABDOMINAL AORTA DUPLEX SCAN:
Date: Sep 16, 2011 Indication: Indication: Hypertension.

Aorta:
Proximal Aortic Diameter: 1.8 cm.
Proximal Aortic Peak Systolic Velocity: 0.82 m/s.
Mid Aortic Diameter: 1.4 cm.
Mid Aortic Peak Systolic Velocity: 0.59 m/s.
Distal Aortic Diameter: 1 cm.
Distal Aortic Peak Systolic Velocity: 0.73 m/s.

Technical impression:
Within normal limits.
There is mild plaque in distal aorta.

————————————————————————————————————————————————————
DIAGNOSIS/ASSESSMENT:

The patient is extremely concerned regarding her cardiac health and wishes to be evaluated and re-assured “frequently.”

H/O LABILE INR.
In-office INR today was 2.5. Continue current Coumadin dose. Will repeat INR on 06/27/16.

MITRAL VALVE DISORDER.
S/p metallic mitral valve replacement on 03/17/11 given a history of severe mitral valve prolapse. Normally functioning prosthetic valve per echocardiography. The patient is stable overall. The patient is on lifelong anticoagulation therapy.

H/O PAROXYSMAL ATRIAL FIBRILLATION.
DILATED LEFT ATRIUM (4.9 cm)
The patient is currently in normal sinus rhythm per EKG. Continue Metoprolol and anticoagulation therapy. She was advised to avoid caffeine, alcohol, and other stimulants, which may precipitate these episodes. She is to contact me or emergency services if she develops palpitations.

HYPERTENSION BENIGN W/O CHF, CONTROLLED.
Controlled. No evidence of left ventricular hypertrophy per echocardiography. Low sodium diet advised.

HYPERLIPIDEMIA.
LDL 105 mg/dL, HDL 47 mg/dL, triglycerides 144 mg/dL per labs on 11/17/15. Continue a low fat diet. May need to consider medical therapy if her lipid profile does not improve with lifestyle modification.

H/O HEMATURIA.
Resolved. Followed by Dr. Mehdizadeh of Urology.

OTHER:
1. H/o TIA, 04/11. Medical records not available to me at this time. Optimal blood pressure and lipid profile advised.
2. H/o Bronchitis, recurrent. Resolved.

DISCUSSION:

PLAN:
Medication changes: No.

Procedures performed today: INR.

Diet: Patient advised to follow a healthy low fat, salt and carbohydrate diet.

Exercise recommendations: Regular exercise is strongly recommended. Recommend gradual increase in daily aerobic exercise.

Hypertension Instructions: The patient was instructed to monitor their blood pressure twice daily and provide me with the records.

Anticoagulation/ Anti-thrombin recommendations: The patient was advised that chronic anticoagulation therapy is recommended for her heart condition. Risks of chronic anticoagulation therapy include, but are not limited to, increased risk of bleeding complications including the possibility of intracranial bleeding, and increased risk of bleeding related to trauma. Given the patient’s increased risk for thromboembolic events, Coumadin therapy is recommended. Careful monitoring is extremely important with chronic anticoagulation therapy. If, during Coumadin therapy, the patient notices any evidence of bleeding or the patient is involved in a traumatic accident, the patient was advised to please notify my office immediately. The patient was advised to try to maintain a consistent intake of green vegetables per day to ensure that their INR levels do not fluctuate dramatically. A blood test called an “INR” will need to be checked every one to two weeks to ensure constant levels of Coumadin therapy.

Preventive Medicine: It is important that the patient follow up with their primary physician for preventative medicine follow ups, including but not limited to, colonoscopy and yearly gynecologic evaluation, mammogram and pap smear.

Follow Up: The patient was advised to return to the office for follow up in 4 days or earlier if she has any medical problems.

Emergency recommendations: The patient was advised to call 911 or go to the emergency room if the patient’s condition worsens or does not improve.

——————————————————————————————————————————————————-

Check in time: 02:34 PM Check out time: 03:14 PM

Electronically signed:

Uri M. Ben-Zur, M.D., F.A.C.C.
Interventional Cardiology / Invasive Electrophysiology

18200 Ventura Blvd
Tarzana, CA 91356
Phone (818) 986-0911 Fax (818) 986-9301
Date of visit: 07/05/2016
Reason for Visit:
Requesting Physician:
I had the opportunity to evaluate n the date stated above. I have reviewed the past medical history, symptoms and current therapy. In addition, I have examined the patient and based on my findings have provided my overall impression, outlining my treatment and plans in the summary below.

CHIEF COMPLAINT /HISTORY OF PRESENT ILLNESS:

is an extremely pleasant 88 year old male with a past medical history of paroxysmal atrial tachycardia, hypertension, and hyperlipidemia. He is accompanied today by his daughter.

The patient was referred for a cardiac evaluation by his internist, Dr. Rose, given abnormal findings on 24 Hr Holter monitoring.

The patient complains of occasional, non exertional left sided chest pressure. He has been experiencing this symptom for an extended period of time, and it has not changed in frequency, severity or duration. The severity of this symptom is mild. The patient indicates no modifying factors. No other associated symptoms noted.

The patient complains of shortness of breath with moderate exertion. The severity of this symptom is mild. It resolves within a few minutes of rest. Associated symptoms include fatigue.

The patient also complains of occasional dizziness with changes of position. No other associated symptoms noted.

The patient’s daughter states that he came back from a trip to El Salvador at the end of May and since then has been exhibiting depressed behavior, generalized weakness and overall deterioration of his condition.

The patient denies palpitations, syncope.

The patient’s blood pressure fluctuates per his home monitor, ranging from 80-180/60-110 mmHg according to his home monitor. The patient does not follow an exercise program. He does not follow a specific diet.

Overall, states that he is feeling worse.
PAST MEDICAL HISTORY:
Cardiovascular:
Hyperlipidemia.
Hypertension, benign essential.
Paroxysmal Atrial Tachycardia.
Genitourinary:
Chronic kidney disease.
Malignancy:
Prostate Cancer. Diagnosed 2006.
Psychiatry:
Anxiety.
Depression.
Endocrine:
Hypothyroidism.
SURGICAL HISTORY:
Cataract extraction, bilateral.
Laser prostate surgery.

CURRENT MEDICATIONS:
1 Carvedilol 3.125 Mg Tablet SIG: take one PO QAM PRN sBP >180 mmHg
2 Gabapentin 300 Mg Capsule SIG: take one PO QHS
3 Haloperidol 0.5 Mg Tablet SIG: take one PO TID
4 Hydralazine 50 Mg Tablet SIG: PO QID PRN sBP >180 mmHg
5 Levothyroxine 88 Mcg Tablet SIG: take one PO QD
6 Losartan Potassium 50 Mg Tab SIG: take one PO QD PRN sBP >180 mmHg
7 Lupron Depot 7.5 Mg Kit SIG: every 2nd month
8 Sertraline Hcl 100 Mg Tablet SIG: take one PO QHS
9 Simvastatin 20 Mg Tablet SIG: take one PO QD
10 Stiolto Respimat SIG: twice daily
11 Tamsulosin Hcl 0.4 Mg Capsule SIG: take one PO QHS
12 Tramadol Hcl 50 Mg Tablet SIG: take one PO Q 8 hrs PRN
13 Trintellex SIG: 10 mg PO QPM

ALLERGIES / INTOLERANCES:
No Known Drug Allergy

SOCIAL HISTORY:
Marital Status: The patient is married. He had 12 children. 3 deceased, 9 alive.
Smoking/tobacco use: No history of smoking.
Alcohol: Non alcoholic beverage drinker.
Recreational drug use: He denies recreational drug use.
Caffeine Intake: Occasional cup of coffee.
Stress Level: High.
Occupation: Retired.

FAMILY HISTORY:
Father is deceased. He died in his 70s.
Mother is deceased. She died in her 70s. Cause of death unknown.
REVIEW OF SYSTEMS:
Constitutional Symptoms: (+) fatigue, (+) weakness.
Constitutional Symptoms: (+) fatigue, (+) weakness.
Integumentary: (-) rash, (-) lumps, (-) itching, (-) dryness, (-) acne, (-) discoloration, (-) recurrent skin infections, (-) changes in hair, nails or moles.

Respiratory: (+) cough.
Respiratory: (+) cough.
Cardiovascular: (+) chest pain non-exertional, (+) dizziness, (+) dyspnea with exertion, (+) edema, (+) high blood pressure, (-) irregular heartbeat, (-) palpitations, (+) shortness of breath, (-) Syncope.
Cardiovascular: (+) chest pain non-exertional, (+) dizziness, (+) dyspnea with exertion, (+) edema, (+) high blood pressure, (+) shortness of breath.
Gastrointestinal: (-) abdominal pain, (+) constipation.
Gastrointestinal: (+) constipation.
Genitourinary: (-) dysuria, (-) frequency, (-) urgency, (-) hesitancy, (-) polyuria, (-) nocturia, (-) hematuria, (-) urinary incontinence, (-) flank pain, (-) change in urinary habits.

Musculoskeletal: (+) joint pain.
Musculoskeletal: (+) joint pain.
Peripheral Vascular: (-) intermittent claudication, (-) cramps, (-) varicose veins, (-) thrombophlebitis.

Neurological: (-) numbness, (-) tingling, (-) tremors, (-) seizures, (-) vertigo, (-) memory loss, (-) any focal or diffuse neurological deficits.

Endocrine: (-) heat or cold intolerance, (-) excessive sweating, (-) excessive thirst, (-) excessive hunger, (-) excessive urination, (-) hirsutism, (-) change in ring or shoe size.

Hematologic/Lymphatic: (-) anemia, (-) easy bruising, (-) excessive bleeding, (-) history of blood transfusions.

PHYSICAL EXAM:
Vitals:
BP: 106/75(Left Arm)(Standing)
Pulse: 71

BP: 126/78(Left Arm)(Sitting)
Pulse: 79

General Appearance: The patient is an extremely pleasant 88 year old male who looks younger than his stated age. is well developed and well nourished in no apparent distress. His body habitus is within normal limits. His mood is normal.
HEENT: Normocephalic and atraumatic. Pupils are equally round and reactive to light and accommodation. Extraocular muscles are intact. Patient’s neck is supple with no jugular venous distention, left carotid bruit was heard and carotid pulses are +2/2. Normal carotid artery upstroke bilaterally. Palpation is not painful and no thyromegaly nor lymphadenopathy can be appreciated.
Respiratory: Clear to auscultation bilaterally without wheezes or rhonchi. No intercostal retractions or accessory muscle use were noted.
Cardiovascular: Regular heart rate and rhythm. Cardiac point of maximal impulse at left fifth intercostal space mid-clavicular line. Normal S1, S2 with physiologic splitting of S2. I/VI systolic murmur. No thrills, rubs, gallops, or clicks were heard.
Gastroenterology: Abdomen is soft non-tender and non-distended. Positive bowel sounds, no hepatomegaly or splenomegaly was noted. No bruits were heard.
Extremities: Pulses were 2+ throughout bilaterally. No cyanosis, edema or clubbing.
Musculoskeletal: Motor strength is appropriately intact throughout bilaterally.
Neurologic: Patient is alert and oriented x3 with deep tendon reflexes appropriately intact throughout bilaterally, non-focal.
Psychiatric: Patient is conscious, cooperative, and well-oriented to time, place, and person. There are no mood swings or psychotic features. Patient’s insight is good. Memory and judgement are intact.
Skin: No skin rash, subcutaneous nodules, lesions or ulcers observed.
DIAGNOSTIC DATA:

ELECTROCARDIOGRAM: Date performed: Jul 3, 2016.
Indication: Shortness of breath, fatigue and requested by Dr. Rose.
Interpretation: Rate: 68 bpm; Rhythm: Normal sinus rhythm, Non-specific ST-T changes and low voltage limb leads; Axis: Left axis deviation.
Conclusion: Abnormal ECG.

2D COLOR DOPPLER ECHOCARDIOGRAPHY:
Date: Jul 3, 2016 Indication: Occasional shortness of breath, Dizziness. fatigue. Referred by Dr. Rose.

Findings:
Left atrium: Dimension: 3.3 cm. (Men: 3-4 cm/Women: 2.7-3.8 cm).
Left ventricle:
-LVIDd = 3.8 cm (Men:4.2-5.9 cm/Women: 3.9-5.3cm).
-LVIDs = 2.2 cm (2.0-4.1 cm).
-IVS = 1.2 cm (0.6-1.1 cm).
-LVPWd = 1.2 cm (0.6-1.1 cm).
Ventricular thickness: There is moderate LV concentric hypertrophy.
Wall kinesis: There is E-A flow reversal suggestive of diastolic dysfunction.

Right atrium: Normal in size and shape and shows no signs of ASD, mass or thrombus.
Right ventricle: RVSP: 40 mmHg (15-25 mmHg).

Aortic valve: Normal trileaflet aortic valve.
Mitral valve: Normal mitral valve without prolapse.
Tricuspid valve: Normal tricuspid valve.
Pulmonic valve: Normal pulmonic valve.
Aorta: Ascending aorta: 2.6 cm. ( 2.1-3.4 cm).

Left ventricle ejection fraction: 60 %.

Pericardium: No effusion or calcification.
Venous: Inferior vena cava: Normal diameter with normal respiratory variation.

CAROTID ARTERY DUPLEX SCAN:
Date of Study: Jul 5, 2016.
Indication: Recurrent dizziness, Left carotid bruit.

Measurements:
Left:
CCA distal peak velocity: 50 cm/sec.
CCA end diastolic velocity: 13 cm/sec.
ICA distal peak velocity: 65 cm/sec.
ICA end diastolic velocity: 21 cm/sec.
ECA distal peak velocity: 67 cm/sec.
ECA end diastolic velocity: 14 cm/sec.
Left vertebral artery showed antegrade flow.
ICA/CCA: 1.3.
Right:
CCA distal peak velocity: 59 cm/sec.
CCA end diastolic velocity: 13 cm/sec.
ICA distal peak velocity: 68 cm/sec.
ICA end diastolic velocity: 21 cm/sec.
ECA distal peak velocity: 75 cm/sec.
ECA end diastolic velocity: 12 cm/sec.
Right vertebral artery showed antegrade flow.
ICA/CCA: 1.2.

Impression/Comments:
Left:
Left CCA: plaque less than 10%.
Left ICA: plaque less than 10%.
Right:
Right CCA: plaque less than 10%.
Right ECA: plaque less than 10%.

Plan:
Non-obstructive disease.
Will intensify medical therapy.

.
Other: 24 Hr Holter monitoring performed on 06/12/16 at Dr. Rose’s office showed paroxysmal atrial tachycardia, 5 beats at 130 bpm.

Colonoscopy: Last colonoscopy was performed in 2013. Results were normal.
Prostate exam: Last urological exam was performed in year 2016.
Patient’s Physicians:
Internist/Primary physician: Dr. Daniel Rose.
Nephrologist: Dr. John Arcia.

————————————————————————————————————————————————————
DIAGNOSIS/ASSESSMENT:

ATYPICAL CHEST PAIN.
Mild. Stable. Unclear etiology. Cannot rule out cardiac etiology, the patient has multiple risk factors for coronary artery disease. EKG revealed normal sinus rhythm, non specific ST-T changes, low voltage limb leads and left axis deviation. Echocardiography revealed mild pulmonary hypertension and mild diastolic dysfunction, EF 60%. Recommend further work up, including myocardial perfusion scanning at his earliest convenience. The patient was advised of the importance of cardiac risk factor modification, including optimal blood pressure, lipid profile, a healthy diet, weight loss and daily aerobic exercise. He is to monitor this symptom carefully, and notify me if it worsens, or changes in pattern/quality.

SHORTNESS OF BREATH/FATIGUE.
Multifactorial. Patient with a sedentary lifestyle and multiple risk factors for coronary artery disease. EKG revealed normal sinus rhythm, non specific ST-T changes, low voltage limb leads and left axis deviation. Echocardiography revealed mild pulmonary hypertension and mild diastolic dysfunction, EF 60%. Recommend myocardial perfusion scanning at his earliest convenience. The patient was advised to contact me or emergency services if these symptoms worsen, or he develops new symptoms.

DIZZINESS.
LEFT CAROTID BRUIT.
Mild. Orthostatic changes on physical examination today. Non obstructive disease per carotid artery Duplex scan today. Recommend that the patient rise slowly from a lying down/seated position, and remain well hydrated at all times. He is to contact me or emergency services if this symptom worsens, or he develops new symptoms.

PAROXYSMAL ATRIAL TACHYCARDIA.
24 Hr Holter monitoring on 06/21/16 showed occasional PAT, 5 beats at 130 bpm. EKG revealed normal sinus rhythm, non specific ST-T changes, low voltage limb leads and left axis deviation. Echocardiography revealed normal left atrial dimensions, no evidence of mitral valve prolapse. Recommend that the patient avoid alcohol, caffeine, and other stimulants which may precipitate this condition. The patient is to contact me or emergency services if he develops palpitations.

HYPERTENSION.
Fluctuating blood pressure readings per the patient’s home monitoring. Mild concentric left ventricular hypertrophy per echocardiography. Recommend that he monitor his blood pressure twice daily and provide me with the records. Target systolic blood pressure in the 110-120 mmHg range recommended. Low salt, healthy diet advised.

HYPERLIPIDEMIA.
Total cholesterol 279 mg/dL, HDL 60 mg/dL LDL 186 mg/dL per labs on 06/17/16. Discontinue Simvastatin. Trial of Atorvastatin. Healthy diet advised. Defer labs and management to Dr. Rose.

LEG EDEMA.
Recommend that the patient raise his lower extremities above heart level for 30 minutes, 3-4 times daily. Low salt, healthy diet advised.

MILD PULMONARY HYPERTENSION.
RVSP 40 mmHg per echocardiography. Will follow with serial imaging.

OTHER:
– Hypothyroidism. Elevated TSH 7.10 uIU/mL per labs on 06/17/16. Free T3 and free T4 within the normal range. The patient is on Levothyroxine. Defer management to Dr. Rose.
– Prostate cancer. The patient is on Lupron. Defer management to his urologist.
– Cough. Defer management to Dr. Rose.
– Depression/anxiety. Recommend practicing relaxation techniques. Defer management to Dr. Rose.
– Chronic kidney disease. BUN 21 mg/dL, Creatinine 1.33 mg/dL, eGFR 51 per labs on 06/17/16. Defer management to Dr. Rose.
– Knee pain/osteoarthritis. Defer management to his orthopedist.

DISCUSSION:

PLAN:
Medication changes: Discontinue Simvastatin. Trial of Atorvastatin 40 mg PO QD.

Procedures performed today: Carotid artery duplex scan.

Procedures to be scheduled: Stress Myocardial Perfusion PET Rubidium scan.

Diet: Patient advised to follow a healthy low fat, salt and carbohydrate diet.

Exercise recommendations: Regular exercise is strongly recommended. Recommend gradual increase in daily aerobic exercise.

Hypertension Instructions: The patient was instructed to monitor their blood pressure twice daily and provide me with the records.

Anxiety recommendations: The patient was advised to practice stress reduction techniques, including but not limited to meditation, deep breathing, yoga and exercise as tolerated.

Preventive Medicine: It is important that the patient follow up with their primary physician for preventative medicine follow ups including yearly prostate exam and annual physical exam.

Follow Up: The patient was advised to return to the office for follow up in 2 days or earlier if he has any medical problems.

Emergency recommendations: The patient was advised to call 911 or go to the emergency room if the patient’s condition worsens or does not improve.

——————————————————————————————————————————————————-
1 Atorvastatin 40 Mg Tablet SIG: Take one tablet daily

Changed/Discontinued Medication(s):
Discontinued: SIMVASTATIN 20 MG TABLET
Check in time: 06:11 AM Check out time: 07:03 AM

Electronically signed: 07/06/2016 03:25 PM BENZUR, URI

99214 Office/outpatient visit, est, mod; G8427 Med.with dosage and verification documented; 1036F CURRENT TOBACCO NON-USER CAD CAP COPD PV DM; 93880 Extracranial arteries study, compl; G8419 BMI abnormal. No followup plan documented

Uri M. Ben-Zur, M.D., F.A.C.C.
Interventional Cardiology / Invasive Electrophysiology

18200 Ventura Blvd
Tarzana, CA 91356
Phone (818) 986-0911 Fax (818) 986-9301
Date of visit: 07/05/2016
Reason for Visit:
Requesting Physician:
I had the opportunity to evaluate on the date stated above. I have reviewed the past medical history, symptoms and current therapy. In addition, I have examined the patient and based on my findings have provided my overall impression, outlining my treatment and plans in the summary below.

CHIEF COMPLAINT /HISTORY OF PRESENT ILLNESS:

Mr. is an extremely pleasant 65 year old male with a past medical history of hypertension, Hashimoto’s thyroiditis, pre diabetes mellitus type II, and a history of paroxysmal atrial tachycardia.

The patient complains of occasional palpitations, described as fast heartbeats. Each episode lasts for a few seconds and resolves spontaneously. No associated symptoms noted. The last episode occurred yesterday.

The patient complains of occasional dizziness upon standing up and with sudden position changes. It is mild in severity. It lasts for a few seconds and resolves spontaneously. Associated symptoms include poor balance.

The patient complains of occasional fatigue. This symptom has existed for an extended period of time and has not changed in severity. It is moderate in severity. Rest improves the symptom. No associated symptoms noted.

The patient denies chest pain, shortness of breath, syncope.

The patient’s blood pressure averages 120/70 mmHg according to his home monitor. Mr. WARD is following an exercise program. He has a brisk walk for 30 minutes daily. He also lifts weights, does push ups and abdominal crunches. He follows a healthy diet.
PAST MEDICAL HISTORY:
Cardiovascular:
Hypertension, benign essential.
Paroxysmal Atrial Tachycardia.
Respiratory:
Sleep Apnea. Uses CPAP machine.
Gastroenterology:
Gastroesophageal Reflux.
Musculoskeletal:
Osteoarthritis.
Neurology:
Neuropathy.
Malignancy:
Basal Cell Carcinoma x 2, once on ear and once on cheek.
Endocrine:
Pre Diabetes Mellitus
Hashimoto’s disease.
Allergy/Immunology:
Allergies: seasonal.
Genetic:
Methyl tetrahydrofolate reductase mutation.
SURGICAL HISTORY:
Left hernia repair.
Excision of cyst from neck at 11.
Excision of basal cell carcinoma from cheek and ear.

CURRENT MEDICATIONS:
1 Flonase 0.05% Nasal Spray 50 Mcg/actuation SIG: As directed
2 Multiple Vitamins And Supplements
3 Diltiazem 30 Mg Tablet SIG: one tab PO TID. Hold if dizzy or standing BP<110 mmHg
4 Liothyronine Sod 5 Mcg Tab SIG: take on tablet QD
5 Levothyroxine 50 Mcg Tablet (Other MD) SIG: Take 1 tab by mouth once daily

ALLERGIES / INTOLERANCES:
Lipase

SOCIAL HISTORY:
Marital Status: The patient is married, with 6 children, 4 of whom are adopted.
Smoking/tobacco use: No history of smoking.
Alcohol: Non alcoholic beverage drinker.
Recreational drug use: He denies recreational drug use.
Caffeine Intake: He does not drink coffee, tea, soda or any other caffeinated drinks and beverages.
Stress Level: Moderate.
Occupation: Engineer.

FAMILY HISTORY:
Father is deceased. He died at the age of 57 due to Pneumonia. H/o diabetes mellitus.
Mother is deceased. She died at the age of 82 due to Mandibular cancer.
2 brothers. Younger brother died of a myocardial infarction at 52. He was overweight and had a history of tobacco use. Older brother is alive, he has hemochromatosis, and psoriatic arthritis.
REVIEW OF SYSTEMS:
Constitutional Symptoms: (+) moderate fatigue.
Constitutional Symptoms: (+) moderate fatigue.
Integumentary: (-) rash, (-) lumps, (-) itching, (-) dryness, (-) acne, (-) discoloration, (-) recurrent skin infections, (-) changes in hair, nails or moles.

Head: (-) headaches, (-) head injury or deformity, (-) visual changes, (-) eye pain, (-) double or blurred vision, (-) hearing changes, (-) tinnitus, (-) vertigo, (-) use of hearing aids, (-) frequent colds, (-) nasal allergies. Ears, Nose, Mouth, Throat: (-) hearing changes, (-) tinnitus, (-) vertigo, (-) dizziness, (-) earache, (-) ear infection, (-) ear discharge, (-) use of hearing aids. Neck: (-) swollen glands, (-) enlarged thyroid, (-) neck pain.

Respiratory: (-) cough, (-) hemoptysis, (-) cyanosis, (-) wheezing, (-) nocturnal choking or gasping.

Cardiovascular: (-) chest pain, (+) dizziness, (-) dyspnea with exertion, (-) edema, (-) high blood pressure, (-) irregular heartbeat, (+) palpitations, (-) shortness of breath, (-) Syncope.
Cardiovascular: (+) dizziness, (+) palpitations.
Gastrointestinal: (-) abdominal pain, (+) constipation, (+) nausea.
Gastrointestinal: (+) constipation, (+) nausea.
Genitourinary: (-) dysuria, (-) frequency, (-) urgency, (-) hesitancy, (-) polyuria, (-) nocturia, (-) hematuria, (-) urinary incontinence, (-) flank pain, (-) change in urinary habits.

Musculoskeletal: (-) muscle pain, (-) joint pain, (-) bone pain.

Peripheral Vascular: (-) intermittent claudication, (-) cramps, (-) varicose veins, (-) thrombophlebitis.

Neurological: (+) numbness, (+) tingling.
Neurological: (+) numbness, (+) tingling.
Endocrine: (-) heat or cold intolerance, (-) excessive sweating, (-) excessive thirst, (-) excessive hunger, (-) excessive urination, (-) hirsutism, (-) change in ring or shoe size.

Hematologic/Lymphatic: (-) anemia, (-) easy bruising, (-) excessive bleeding, (-) history of blood transfusions.

PHYSICAL EXAM:
Vitals:
Weight: 175 lbs
Height: 6′ 1″
BMI: 23.09
BSA: 2.02
BP: 124/70(Left Arm)(Supine)
Pulse: 69(Left brachial)(Supine)

BP: 120/70(Left Arm)(Standing)
Pulse: 66(Left brachial)(Supine)

General Appearance: The patient is an extremely pleasant 65 year old male who looks younger than his stated age. is well developed and well nourished in no apparent distress. His body habitus is within normal limits. His mood is normal.
HEENT: Normocephalic and atraumatic. Pupils are equally round and reactive to light and accommodation. Extraocular muscles are intact. Patient’s neck is supple with no jugular venous distention, right carotid bruit was heard and carotid pulses are +2/2. Normal carotid artery upstroke bilaterally. Palpation is not painful and no lymphadenopathy can be appreciated. Mild thyromegaly noted.
Respiratory: Clear to auscultation bilaterally without wheezes or rhonchi. No intercostal retractions or accessory muscle use were noted.
Cardiovascular: Regular heart rate and rhythm. Cardiac point of maximal impulse at left fifth intercostal space mid-clavicular line. Normal S1, S2 with physiologic splitting of S2. No murmurs, thrills, rubs, gallops, or clicks were heard.
Gastroenterology: Abdomen is soft non-tender and non-distended. Positive bowel sounds, no hepatomegaly or splenomegaly was noted. No bruits were heard.
Extremities: Pulses were 2+ throughout bilaterally. No cyanosis, edema or clubbing.
Musculoskeletal: Motor strength is appropriately intact throughout bilaterally.
Neurologic: Patient is alert and oriented x3 with deep tendon reflexes appropriately intact throughout bilaterally, non-focal.
Psychiatric: Patient is conscious, cooperative, and well-oriented to time, place, and person. There are no mood swings or psychotic features. Patient’s insight is good. Memory and judgement are intact.
DIAGNOSTIC DATA:

ELECTROCARDIOGRAM: Date performed: Jun 3, 2016.
Indication: Palpitations, h/o recurrent atrial arrhythmias.
Interpretation: Rate: 61 bpm; Rhythm: Normal sinus rhythm; Axis: Right axis deviation.
Conclusion: Abnormal ECG.

2D COLOR DOPPLER ECHOCARDIOGRAPHY:
Date: Mar 11, 2016 Indication: Palpitations, Abnormal EKG.

Findings:
Left atrium: Dimension: 3.3 cm. (Men: 3-4 cm/Women: 2.7-3.8 cm). Normal in size.
Left ventricle:
-LVIDd = 3.2 cm (Men:4.2-5.9 cm/Women: 3.9-5.3cm).
-LVIDs = 2.5 cm (2.0-4.1 cm).
-IVS = 0.8 cm (0.6-1.1 cm).
-LVPWd = 0.7 cm (0.6-1.1 cm).
Ventricular thickness: Within normal limits.
Cavity dimension: Normal.
Wall kinesis: Normal contraction.

Right atrium: Normal in size and shape and shows no signs of ASD, mass or thrombus.
Right ventricle: RVSP: 34 mmHg (15-25 mmHg). Normal in size and shape and shows no evidence of VSD or mass.

Left ventricle ejection fraction: 60 %.

Pericardium: No effusion or calcification.
Venous: Inferior vena cava: Normal diameter with normal respiratory variation.

TREADMILL STRESS TEST/W STRESS ECHOCARDIOGRAPHY.
Date: Jun 3, 2016. Indication: Palpitations, Abnormal EKG
Risk and benefits of exercise stress test including but not limited to myocardial infarction, vascular compromise and death were explained to Mr. WARD in detail. The patient asked appropriate questions. All questions were answered. The patient wished to proceed and gave his informed consent.

Protocol: Standard Bruce protocol.

Procedure:
STAGE I (Min 0 to 2:50): Min: 2 . MPH: 1.7. Grade: 10 %. MET: 1-5. BP: 138/85, Pulse: 84, O2 Sat: 98.
STAGE II (Min 3 to 5:50): Min: 5 . MPH: 2.5. Grade: 12%. MET: 6-7. BP: 138/85, Pulse: 105, O2 Sat: 98.
STAGE III (Min 6 to 8:50): Min: 8 . MPH: 3.4. Grade: 14%. MET 8-10. BP: 145/85, Pulse: 133, O2 Sat: 98.

Results:
Maximal Predicted Heart Rate: 155 bpm.
Peak heart rate achieved: 156 bpm.
Maximal heart rate achieved: 100 % of predicted heart rate.
Average O2 saturation throughout the study: 98 %.
Total Minutes: 10.15.
Reason for stopping: Target heart rate achieved.

Clinical response:
Peak exercise electrocardiogram demonstrated no significant ischemic changes nor arrhythmias.

Stress echocardiography:
Revealed normal left ventricular function at rest with an adequate increase in left ventricular function in response to exercise.

Findings:
1. Normal right heart size and function
2. Left heart size dimensions are normal.
3. Left ventricular ejection fraction is normal at 65%.
4. Global systolic function normal.
5. Normal valvular structure.
6. No pericardial effusion.

Summary: The patient exercised according to the BRUCE protocol for a total of 10.15 minutes, achieving a peak heart rate of 156 bpm, 100% of the maximum predicted heart rate. Electrocardiogram showed no significant ST-T changes. Atrial premature contractions/ventricular premature contractions/dysrhythmias were not seen.
Symptoms at peak exercise: The patient had no symptoms and tolerated the exercise well.
The study revealed an adequate cardiovascular exercise stress test with a normal hemodynamic response to exercise.

CAROTID ARTERY DUPLEX SCAN:
Date of Study: Aug 9, 2015.
Indication: Right carotid bruit.

Measurements:
Left:
CCA distal peak velocity: 85 cm/sec.
CCA end diastolic velocity: 27 cm/sec.
ICA distal peak velocity: 89 cm/sec.
ICA end diastolic velocity: 36 cm/sec.
ECA distal peak velocity: 102 cm/sec.
ECA end diastolic velocity: 18 cm/sec.
Left vertebral artery showed antegrade flow.
ICA/CCA: 1.
Right:
CCA distal peak velocity: 66 cm/sec.
CCA end diastolic velocity: 20 cm/sec.
ICA distal peak velocity: 70 cm/sec.
ICA end diastolic velocity: 30 cm/sec.
ECA distal peak velocity: 94 cm/sec.
ECA end diastolic velocity: 18 cm/sec.
Right vertebral artery showed antegrade flow.
ICA/CCA: 1.1.

Impression/Comments:

Findings: Bilateral minimal plaque.

Plan:
Non-obstructive disease.
Will intensify medical therapy.

RENAL ARTERY-AORTA DUPLEX SCAN: Aug 11, 2015.
Indication: Hypertension (401.1).

Measurements:
Left Renal Peak Systolic Velocity:
Proximal: 0.5 m/s [<1.0].
Mid: 0.52 m/s [<1.0].
Distal: 0.67 m/s [<1.0].
Renal/Aortic Ratio: 0.9. [<3.5].
Right Renal Peak Systolic Velocity:
Proximal: 0.43 m/s [<1.0].
Mid: 0.57 m/s [<1.0].
Distal: 0.39 m/s [<1.0].
Renal/Aortic Ratio: 0.8. [<3.5].

Aorta:
Proximal Aortic Diameter: 2.2 cm.
Mid Aortic Diameter: 1.6 cm.
Distal Aortic Diameter: 1.1 cm.
Aortic Peak Systolic Velocity: 0.74 m/s.

Kidney:
Left:
kidney length: 10.5 cm [8.5-15.0 cm].
Kidney Width: 4.9 cm. ( 4.5-5.0 cm].
Kidney Depth (trans): 4.3 cm. [4.5-5.0].
Cortical Thickness: 1.3 cm. [1.1 cm].
Parenchymal Flow /Waveform:
Upper Early Systolic Peak Present.
Mid Early Systolic Peak Present.
Lower Early Systolic Peak Present.
Resistive Index: 0.56 [<0.75] (PSV-EDV/PSV).

Right:
kidney length: 10.2 cm [8.5-15.0 cm].
Kidney Width: 3.8 cm. ( 4.5-5.0 cm].
Kidney Depth (trans): 4.5 cm. [4.5-5.0].
Cortical Thickness: 0.9 cm. [1.1 cm].
Parenchymal Flow /Waveform:
Upper Early Systolic Peak Present.
Mid Early Systolic Peak Present.
Lower Early Systolic Peak Present.
Resistive Index: 0.62 [<0.75]
(PSV-EDV/PSV).

Technical impression:
Within normal limits.

ABDOMINAL AORTA DUPLEX SCAN:
Date: Aug 10, 2015 Indication: Indication: Hypertension (401.1) Plaque.

Aorta:
Proximal Aortic Diameter: 1.9 cm.
Proximal Aortic Peak Systolic Velocity: 0.92 m/s.
Mid Aortic Diameter: 1.5 cm.
Mid Aortic Peak Systolic Velocity: 0.73 m/s.
Distal Aortic Diameter: 1.2 cm.
Distal Aortic Peak Systolic Velocity: 0.82 m/s.

Technical impression:
Minimal plaque seen in abdominal aorta.

Colonoscopy: Last colonoscopy was performed in 2013 Results were normal.
Prostate exam: Last urological exam was performed in 2014.
Patient’s Physicians:
Internist/Primary physician: Dr. Shilpa Sayana: Ph 818-331-4386.
NP: Alexis Rheinwald Jones: Ph 818-331-4386.

————————————————————————————————————————————————————
DIAGNOSIS/ASSESSMENT:

PALPITATIONS.
H/O PAROXYSMAL ATRIAL TACHYCARDIA.
EKG revealed normal sinus rhythm, and right axis deviation. Echocardiography revealed normal left atrial dimensions, no evidence of mitral valve prolapse. Previous Holter monitoring showed recurrent paroxysmal atrial tachycardia. No exercise induced arrhythmias per stress test. The patient denied a trial of Flecainide secondary to concerns about potential adverse effects. Continue Diltiazem. Recommend that the patient avoid alcohol, caffeine, and other stimulants, which may precipitate his condition. He is to contact me if his condition worsens, or he develops new symptoms.

FATIGUE.
Moderately symptomatic as he has trouble staying awake throughout the work day. Echocardiogram revealed normal systolic function, EF 60%. The patient was advised of the importance of following a healthy diet and daily aerobic exercise. He is to contact me or emergency services if this symptom worsens, or he develops new symptoms.

DIZZINESS/POOR BALANCE.
No orthostatic changes on physical examination today. Non-obstructive disease per carotid artery Duplex scan. Patient to rise slowly from a lying down/seated position, and remain well hydrated at all times. He is to contact me if this symptom worsens, or he develops new symptoms.

HYPERTENSION.
Controlled. No evidence of left ventricular hypertrophy per echocardiography. No evidence of renal artery stenosis or abdominal aortic aneurysm per Duplex scan. Continue Diltiazem. The patient is to monitor his blood pressure twice daily and provide me with the records. Target systolic blood pressure in the 110-120 mmHg range recommended. Low salt, healthy diet advised.

PRE-DIABETES MELLITUS.
HbA1c 5.5% per labs on 01/29/16. Low carbohydrate, healthy diet advised.

OTHER:
– Hashimoto’s thyroiditis. The patient is on Levothyroxine and Liothyronine. Defer management to Dr. Sayana.
– Sleep apnea. Per the patient’s account, his CPAP machine showed episode of Cheyne-Stokes breathing while he was at high altitude. Will defer management to his pulmonologist.
– Constipation. Per the patient’s account, it is manageable. Recommend that he increase his fiber intake. Recommend follow up with a gastroenterologist.
– Numbness/tingling. Recommend evaluation by a neurologist.

DISCUSSION:

PLAN:
Medication changes: No.

Diet: Patient advised to follow a healthy low fat, salt and carbohydrate diet.

Exercise recommendations: Regular exercise is strongly recommended. Recommend gradual increase in daily aerobic exercise.

Hypertension Instructions: The patient was instructed to monitor their blood pressure twice daily and provide me with the records.

Preventive Medicine: It is important that the patient follow up with their primary physician for preventative medicine follow ups including yearly prostate exam and annual physical exam.

Follow Up: The patient was advised to return to the office for follow up in 4 week or earlier if he has any medical problems.

Emergency recommendations: The patient was advised to call 911 or go to the emergency room if the patient’s condition worsens or does not improve.

——————————————————————————————————————————————————-

Check in time: 06:56 AM Check out time: 07:26 AM

Electronically signed: 07/06/2016 03:25 PM BENZUR, URI

99213 Office/outpatient visit, est, mod

Uri M. Ben-Zur, M.D., F.A.C.C.
Interventional Cardiology / Invasive Electrophysiology

18200 Ventura Blvd
Tarzana, CA 91356
Phone (818) 986-0911 Fax (818) 986-9301
Date of visit: 07/05/2016
Reason for Visit:
Requesting Physician:
I had the opportunity to evaluate on the date stated above. I have reviewed the past medical history, symptoms and current therapy. In addition, I have examined the patient and based on my findings have provided my overall impression, outlining my treatment and plans in the summary below.

CHIEF COMPLAINT /HISTORY OF PRESENT ILLNESS:

Mr is an extremely pleasant 59 year old male with a past medical history of hypertension and hyperlipidemia.

The patient is being seen frequently given fluctuating blood pressures and multiple medication adjustments. At the time of the last visit, the patient was instructed to take Edarbyclor 40-12.5 mg QAM and Edarbi 40 mg PO QPM. He complied and reports increasing dizziness on this regimen. He reports that he had one episode of syncope while on this regimen. He was leaning against a wall, when he suddenly felt dizzy and lost consciousness. No other associated symptoms noted.

The patient denies chest pain, shortness of breath, palpitations. The patient does not follow an exercise program. He does not follow a specific diet.
PAST MEDICAL HISTORY:
Cardiovascular:
Hyperlipidemia.
Hypertension, benign essential.
Respiratory:
Lobar pneumonia, 1973.
Gastroenterology:
Gastroesophageal Reflux.
Musculoskeletal:
Chronic low back pain.
Neurology:
Facial tics.
Genitourinary:
Enlarged prostate, 2006.
HEENT:
Eye blindness, congenital, right eye.
Psychiatry:
Anxiety.
Attention Deficit Hyperactivity Disorder.
SURGICAL HISTORY:
Vasectomy in 1991
Tonsillectomy in 1962
Bladder surgery on 8/29/12.

CURRENT MEDICATIONS:
1 Strattera 40 Mg Capsule SIG: Take 2 capsules by mouth daily
2 Lexapro 20 Mg Tablet SIG: Take 1 tablet by mouth once daily
3 Aspirin Ec 81 Mg Tab SIG: take one tablet daily
4 Bystolic 5 Mg Tablet SIG: Take 1/2 tablet PO BID PRN if bp >140
5 Omeprazole Dr 40 Mg Capsule (Other MD) SIG: Take 1 cap by mouth daily
6 Edarbi 40 Mg Tablet (Other MD) SIG: Take 1 tablet QD
7 Edarbyclor 40-12.5 Mg Tablet (Other MD) SIG: take 1 tablet QAM

ALLERGIES / INTOLERANCES:
Niacin, spironolactone, Calcium Channel Blockers, Statins-Hmg-Coa Reductase Inhibitors

SOCIAL HISTORY:
Marital Status: The patient is married, with 2 healthy children.
Smoking/tobacco use: No history of smoking.
Alcohol: The patient rarely drinks alcoholic beverages. 1-2 glasses of wine/year.
Recreational drug use: He denies recreational drug use.
Caffeine Intake: Occasional decaf coffee.
Stress Level: Low to moderate.
Occupation: Attorney.

FAMILY HISTORY:
Father deceased at 73 from heart failure. H/o hypertension, pacemaker, carotid endarterectomy x2
Mother alive. H/o Hypertension, Coronary artery disease, H/O Arrhythmias, Parkinson’s Disease, Breast cancer S/P partial mastectomy at 78, sleep apnea.
REVIEW OF SYSTEMS:
Constitutional Symptoms: (-) fever, (-) chills, (-) night sweats, (-) fatigue, (-) weakness, (-) changes in appetite or weight.

Integumentary: (-) rash, (-) lumps, (-) itching, (-) dryness, (-) acne, (-) discoloration, (-) recurrent skin infections, (-) changes in hair, nails or moles.

Respiratory: (-) cough, (-) hemoptysis, (-) cyanosis, (-) wheezing, (-) nocturnal choking or gasping.

Cardiovascular: (-) chest pain, (+) dizziness, (-) dyspnea with exertion, (-) edema, (-) high blood pressure, (-) irregular heartbeat, (-) orthopnea, (-) palpitations, (-) paroxysmal nocturnal dyspnea, (+) Syncope.
Cardiovascular: (+) dizziness, (+) Syncope.
Gastrointestinal: (-) abdominal pain, (-) heartburn, (-) constipation, (-) diarrhea, (-) nausea, (-) vomiting, (-) hematochezia, (-) melena, (-) change in bowel habits.

Genitourinary: (-) dysuria, (-) frequency, (-) urgency, (-) hesitancy, (-) polyuria, (-) nocturia, (-) hematuria, (-) urinary incontinence, (-) flank pain, (-) change in urinary habits.

Musculoskeletal: (-) muscle pain, (-) joint pain, (-) bone pain.

Peripheral Vascular: (-) intermittent claudication, (-) cramps, (-) varicose veins, (-) thrombophlebitis.

Neurological: (-) numbness, (-) tingling, (-) tremors, (-) seizures, (-) vertigo, (-) memory loss, (-) any focal or diffuse neurological deficits.

Endocrine: (-) heat or cold intolerance, (-) excessive sweating, (-) excessive thirst, (-) excessive hunger, (-) excessive urination, (-) hirsutism, (-) change in ring or shoe size.

Hematologic/Lymphatic: (-) anemia, (-) easy bruising, (-) excessive bleeding, (-) history of blood transfusions.

PHYSICAL EXAM:
Vitals:
BP: 130/75(Left Arm)(Supine)
Pulse: 75(Left brachial)(Supine)(Regular)

Weight: 209 lbs 8 oz
Height: 6′ 1″
BMI: 27.64
BSA: 2.21
BP: 119/81(Left Arm)(Standing)
Pulse: 78(Left brachial)(Standing)(Regular)

General Appearance: The patient is an extremely pleasant 59 year old male who looks younger than his stated age. is well developed and well nourished in no apparent distress. His body habitus is overweight, his mood is normal.
HEENT: Normocephalic and atraumatic. Pupils are equally round and reactive to light and accommodation. Extraocular muscles are intact. Patient’s neck is supple with no jugular venous distention, no stridor, no carotid bruits were heard and carotid pulses are +2/2. Normal carotid artery upstroke bilaterally. Palpation is not painful and no thyromegaly nor lymphadenopathy can be appreciated.
Respiratory: Clear to auscultation bilaterally without wheezes or rhonchi. No intercostal retractions or accessory muscle use were noted.
Cardiovascular: Regular heart rate and rhythm. Cardiac point of maximal impulse at left fifth intercostal space mid-clavicular line. Normal S1, S2 with physiologic splitting of S2. No murmurs, thrills, rubs, gallops, or clicks were heard.
Gastroenterology: Abdomen is soft non-tender and non-distended. Positive bowel sounds, no hepatomegaly or splenomegaly was noted.
Extremities: Pulses were 2+ throughout bilaterally. No cyanosis, edema or clubbing.
Musculoskeletal: Motor strength is appropriately intact throughout bilaterally.
Neurologic: Patient is alert and oriented x3 with deep tendon reflexes appropriately intact throughout bilaterally, non-focal.
Psychiatric: Patient is conscious, cooperative, and well-oriented to time, place, and person. There are no mood swings or psychotic features. Patient’s insight is good. Memory and judgement are intact.
Skin: No skin rash, subcutaneous nodules, lesions or ulcers observed.
DIAGNOSTIC DATA:

ELECTROCARDIOGRAM: Date performed: Apr 22, 2016.
Indication: Occasional shortness of breath.
Interpretation: Rate: 68 bpm; Rhythm: Normal sinus rhythm and Non-specific ST-T changes.
Conclusion: Abnormal ECG.

2D COLOR DOPPLER ECHOCARDIOGRAPHY:
Date: Apr 22, 2016 Indication: Occasional shortness of breath.

Findings:
Left atrium: Normal in size and shape and shows no signs of ASD, mass or thrombus.
Left ventricle: Cavity size: Normal.
Wall thickness: Normal.
Ventricle kinesis: Normal.
Global systolic function: Normal.
Diastolic function: Normal.

Right atrium: Normal in size and shape and shows no signs of ASD, mass or thrombus.
Right ventricle: Normal in size and shape and shows no signs of VSD, mass or thrombus.

Aortic valve: Normal trileaflet aortic valve.
Mitral valve: Trace regurgitation.
Tricuspid valve: Normal tricuspid valve.
Pulmonic valve: Normal pulmonic valve.
Aorta: No evidence of dissection, coarctation or aneurysm of the aorta.

Left ventricle ejection fraction: 65 %.

Pericardium: No effusion or calcification.
Venous: Inferior vena cava: Normal diameter with normal respiratory variation.

TREADMILL STRESS TEST/W STRESS ECHOCARDIOGRAPHY.
Date: May 1, 2014. Indication: Occasional shortness of breath, Abnormal EKG
Risk and benefits of exercise stress test including but not limited to myocardial infarction, vascular compromise and death were explained to Mr. DUSHKES in detail. The patient asked appropriate questions. All questions were answered. The patient wished to proceed and gave his informed consent.

Protocol: Standard Bruce protocol.

Procedure:
STAGE II (Min 3 to 5:50): Min: 3 . MPH: 2.5. Grade: 12%. MET: 6-7. BP: 138/90, Pulse: 102, O2 Sat: 96.
STAGE III (Min 6 to 8:50): Min: 6 . MPH: 3.4. Grade: 14%. MET 8-10. BP: 148/92, Pulse: 118, O2 Sat: 97.

Results:
Maximal Predicted Heart Rate: 163 bpm.
Peak heart rate achieved: 168 bpm.
Maximal heart rate achieved: 100 % of predicted heart rate.
Average O2 saturation throughout the study: 99 %.
Total Minutes: 12.
Reason for stopping: Target heart rate achieved.

Clinical response:
Peak exercise electrocardiogram demonstrated no significant ischemic changes nor arrhythmias.

Stress echocardiography:
Revealed normal left ventricular function at rest with an adequate increase in left ventricular function in response to exercise.

Summary: The patient exercised according to the BRUCE protocol for a total of 12 minutes, achieving a peak heart rate of 168 bpm, 100% of the maximum predicted heart rate. Electrocardiogram showed no significant ST-T changes. Atrial premature contractions/ventricular premature contractions/dysrhythmias were not seen.
Blood pressure response to exercise was normal at 150/95 mmHg.
Symptoms at peak exercise: The patient had no symptoms and tolerated the exercise well.
The study revealed an adequate cardiovascular exercise stress test with a normal hemodynamic response to exercise.

CAROTID ARTERY DUPLEX SCAN:

Date: 8/20/2009. Indication: Dizziness, Right carotid bruit.
RIGHT
Right External Carotid Artery Velocity: 90 cm/s
Right Distal Internal Carotid Artery Velocity: 54 cm/s
Right Distal Common Carotid Artery Velocity: 93 cm/s
Right Internal Carotid Artery/Common Carotid Artery Ratio: 0.6
Right vertebral artery flow is antegrade.
LEFT
Left External Carotid Artery Velocity: 59 cm/s
Left Distal Internal Carotid Artery Velocity: 79 cm/s
Left Distal Common Carotid Artery Velocity: 77 cm/s
Left Internal Carotid Artery/Left Common Carotid Artery Ratio: 1.0
Left vertebral artery flow is antegrade.
Impression RIGHT: RT ICA plaque <10%
Impression LEFT: LT CCA mild intimal thickening, LT BULB plaque <10% and LT ECA plaque <10%
Plan: Non-obstructive disease and will intensify medical therapy.

LOWER EXTREMITIES VENOUS DOPPLER: Oct 6, 2013.
Indication: Trace bilateral leg edema, occasional leg cramps.
Impression: Normal venous flow with normal collapse with compression. Normal augmentation of venous flow with calf compression. No evidence of venous insufficiency with valsalva manuever or abdominal pressure. Normal lower extremities. The Doppler signals were phasic with good augmentation.
The images showed widely patent veins that were fully compressible.
No evidence of deep venous thrombosis or venous outflow obstruction of the lower extremities by duplex scanning.

RENAL ARTERY-AORTA DUPLEX SCAN: Jul 31, 2011 Indication: Hematuria, Uncontrolled Hypertensive heart disease w/o heart failure.

Measurements:
Left Renal Peak Systolic Velocity:
Proximal: 0.6 m/s [<1.0].
Mid: 0.45 m/s [<1.0].
Distal: 0.24 m/s [<1.0].
Renal/Aortic Ratio: 1.6. [<3.5].
Right Renal Peak Systolic Velocity:
Proximal: 0.6 m/s [<1.0].
Mid: 0.83 m/s [<1.0].
Distal: 0.41 m/s [<1.0].
Renal/Aortic Ratio: 1.2. [<3.5].

Aorta:
Proximal Aortic Diameter: 2.2 cm.
Mid Aortic Diameter: 1.6 cm.
Distal Aortic Diameter: 1.1 cm.

Kidney:
Left:
kidney length: 11.4 cm [8.5-15.0 cm].
Kidney Width: 6.2 cm. ( 4.5-5.0 cm].
Kidney Depth (trans): 5.5 cm. [4.5-5.0].
Cortical Thickness: 2.2 cm. [1.1 cm].
Parenchymal Flow /Waveform:
Upper Early Systolic Peak Present. yes.
Mid Early Systolic Peak Present. yes.
Lower Early Systolic Peak Present. yes.
Resistive Index: 0.65 [<0.75] (PSV-EDV/PSV).

Right:
kidney length: 9.9 cm [8.5-15.0 cm].
Kidney Width: 5.9 cm. ( 4.5-5.0 cm].
Kidney Depth (trans): 5.8 cm. [4.5-5.0].
Cortical Thickness: 2.1 cm. [1.1 cm].
Parenchymal Flow /Waveform:
Upper Early Systolic Peak Present. yes.
Mid Early Systolic Peak Present. yes.
Lower Early Systolic Peak Present. yes.
Resistive Index: 0.58 [<0.75]
(PSV-EDV/PSV).

Technical impression:
Within normal limits.
ABDOMINAL AORTA DUPLEX SCAN:
Date: Nov 3, 2013 Indication: Indication: Hypertension (401.1) and abdominal bruit.

Aorta:
Proximal Aortic Diameter: 1.9 cm.
Proximal Aortic Peak Systolic Velocity: 1.07 m/s.
Mid Aortic Diameter: 1.6 cm.
Mid Aortic Peak Systolic Velocity: 0.95 m/s.
Distal Aortic Diameter: 1.2 cm.
Distal Aortic Peak Systolic Velocity: 0.99 m/s.

Technical impression:
Within normal limits. Minimal plaque seen in abdominal aorta.

Other: Venous doppler done on 10/5/2009 Indication: trace to 1+ bilateral leg edema, normal venous system without evidence of occlusion, normal doppler venous signal with spontaneous respiration and shows normal venous flow with normal collapse with compression. Normal augmentation of venous flow with calf compression. No evidence of venous insufficiency with valsalva maneuver or abdominal pressure. Normal lower extremities.

Urinalysis Report: Date: Aug 28, 2012.
Leukocytes: No Leukocytes present.
Nitrite: Negative.
Urobilinogen: (Normal 0.2 – 1).
Protein: Negative.
Ph: 5.
Blood: Blood: Negative.
Specific Gravity: 1.015.
Ketone: Negative.
Bilirubin: Negative.
Glucose: Negative.

Colonoscopy: Last colonoscopy was performed in 2014 Results were normal.
Endoscopy: 09/21/2012. Results revealed reflux esophagitis, negative H. pylori, and no evidence dysplasia or malignancy.

————————————————————————————————————————————————————
DIAGNOSIS/ASSESSMENT:

DIZZINESS/EPISODE OF SYNCOPE.
Likely medication related. No orthostatic changes on physical examination today. Adjust medications today. Recommend that the patient rise slowly from a lying down/seated position, and remain well hydrated at all times. He is to contact me or emergency services if these symptoms worsen or he develops new symptoms.

HYPERTENSIVE HEART DISEASE.
No evidence of renal artery stenosis/abdominal aortic aneurysm/LVH on prior diagnostic studies. Adjust medications today given dizziness/history of syncope. Recommend target systolic blood pressure between 110-120 mmHg. I had a long discussion with the patient about the importance of low salt diet, weight loss, and daily aerobic exercise for better blood pressure control.

DYSLIPIDEMIA.
LDL 116 mg/dL and HDL 40 mg/dL as of 06/23/16. The patient was advised to follow a healthy, low fat diet.

OVERWEIGHT PATIENT.
Recommend BMI less than 25. The patient has lost weight and he is trying to lose more weight with diet and exercise.

OTHER:
1. GERD/bloating. Upper endoscopy on 09/21/12 revealed reflux esophagitis, negative H. pylori and urease. Defer management to Dr. Jacobs.
2. History of hemorrhoids/occasional rectal bleeding/history of constipation. Recent colonoscopy was unremarkable. Defer management to Dr. Jacobs.
3. Benign Prostatic Hypertrophy/Enlarged prostate. No indication for medical therapy at this time, per Dr. Navon. Annual DRE and PSA advised. Defer management to Dr. Navon.
4. Erectile dysfunction. Defer management to Dr. Navon.
5. Anxiety. The patient is on Lexapro. Stress reduction and practicing relaxation techniques advised.

DISCUSSION:

PLAN:
Medication changes: Hold Edarbi and Edarbychlor x 3 days. Then return to previous regimen of Edarbi 40mg one tablet PO QOD alternating with Edarbychlor 40-12.5 mg one tablet PO QOD.

Diet: Patient advised to follow a healthy low fat, salt and carbohydrate diet.

Exercise recommendations: Regular exercise is strongly recommended.

Hypertension Instructions: The patient was instructed to monitor their blood pressure twice daily and provide me with the records.

GERD recommendations: The patient was advised not to eat at least 3 hours before going to bed, to sleep at a 45-degree angle, and to avoid caffeine and spicy foods. Referred patient to online resources for informational material regarding GERD.

Anxiety recommendations: The patient was advised to practice stress reduction techniques, including but not limited to meditation, deep breathing, yoga and exercise as tolerated.

Preventive Medicine: It is important that the patient follow up with their primary physician for preventative medicine follow ups including yearly prostate exam and annual physical exam.

Follow Up: The patient was advised to return to the office for follow up in 3 days or earlier if he has any medical problems.

Emergency recommendations: The patient was advised to call 911 or go to the emergency room if the patient’s condition worsens or does not improve.

——————————————————————————————————————————————————-
Changed/Discontinued Medication(s):
Discontinued: EDARBI 40 MG TABLET – hold due to hypotension
Discontinued: EDARBYCLOR 40-12.5 MG TABLET – hold due to hypotension
Check in time: 07:03 AM Check out time: 08:07 AM

Electronically signed: 07/06/2016 10:56 AM BENZUR, URI

99200 CASH VISIT

Uri M. Ben-Zur, M.D., F.A.C.C.
Interventional Cardiology / Invasive Electrophysiology

18200 Ventura Blvd
Tarzana, CA 91356
Phone (818) 986-0911 Fax (818) 986-9301
Date of visit: 07/05/2016
Reason for Visit:
Requesting Physician:
I had the opportunity to evaluate on the date stated above. I have reviewed the past medical history, symptoms and current therapy. In addition, I have examined the patient and based on my findings have provided my overall impression, outlining my treatment and plans in the summary below.

CHIEF COMPLAINT /HISTORY OF PRESENT ILLNESS:

Mr. MARK SHPIZEAR is an extremely pleasant 63 year old male with a past medical history of severe coronary artery disease s/p percutaneous coronary intervention with atherectomy and stent placement in RCA on 8/18/10, with stent placement in LAD x2 on 10/13/12, recent onset persistent atrial fibrillation status post RFA on 4/6/16, hypertensive heart disease, hyperlipidemia, and diabetes.

The patient complains of occasional bilateral leg swelling. It is mild in severity. It is noticeable at the end of the day and resolves the following morning. No associated symptoms or modifying factors noted.

The patient denies chest pain, shortness of breath, palpitations, dizziness, syncope.

The patient’s blood pressure averages 110-120/70’s mmHg according to his home monitor. Mr. SHPIZEAR is following an exercise program. He walks for minutes, daily. He follows a healthy vegetarian diet.

At the time of his last visit, no medication changes were made.

Overallstates that he has been improving.
PAST MEDICAL HISTORY:
Cardiovascular:
Paroxysmal Atrial Fibrillation.
Coronary Artery Disease.
Hypertensive heart disease w/o CHF, difficult to control.
Status post syncope and collapse on 11/21/11.
Respiratory:
Lung nodules- metabolically inactive per PET-CT scan 8/17/10.
HEENT:
Retinal Detachment. followed by infection- complete loss of vision in left eye.
Endocrine:
Diabetes mellitus.
Trauma or Toxins:
Motor Vehicle Accident. 08/04/10.
SURGICAL HISTORY:
Status post left heart cardiac catheterization, LV angiography and selective bilateral renal angiography. 08/18/10
Status post right coronary artery atherectomy. 08/18/10
S/p Percutaneous coronary intervention balloon dilatation and stent placement (A 2.5 x 15 mm Xience drug-eluting stent) to the right coronary artery. 08/18/10
S/p cardiac catheterization, 08/25/2010. Unsuccessful attempted revascularization of occluded circumflex artery.
S/p cardiac catheterization and stent placement x 2 (2.5 x 12 mm Xience drug eluting stent, and 2.5 x 28 mm Xience drug eluting stent) to the LAD on 10/13/12.
TEE guided DCCV at Providence Tarzana Medical Center on 03/16/16
S/p Comprehensive electrophysiology study/atrial fibrillation radiofrequency ablation on 04/06/16.

CURRENT MEDICATIONS:
1 Nifedipine 90 Mg Tablet SIG: 1 DAILY
2 Benicar 40 Mg Tablet SIG: one tab PO QD
3 Metoprolol Succ Er 50 Mg Tab SIG: Take 2 tablets daily in the morning
4 Metformin 500 Mg Tablet SIG: 1 DAILY
5 Pravachol 80 Mg Tablet SIG: 1 DAILY
6 Pradaxa 150 Mg Capsule SIG: Take one twice daily

ALLERGIES / INTOLERANCES:
No Known Drug Allergy

SOCIAL HISTORY:
Marital Status: The patient is married, with 4 healthy children.
Smoking/tobacco use: H/o tobacco use, 35 pack years, discontinued in 2008.
Alcohol: The patient drinks alcoholic beverages. He drinks red wine socially.
Recreational drug use: He denies recreational drug use.
Caffeine Intake: Drinks 2 cups of coffee/day.
Occupation: Sales.

FAMILY HISTORY:
Father deceased in his 90’s. Cause of death unclear.
Mother deceased at 80, h/o diabetes and hypertension.
REVIEW OF SYSTEMS:
Constitutional Symptoms: (-) fever, (-) chills, (-) night sweats, (-) fatigue, (-) weakness, (-) changes in appetite or weight.

Integumentary: (-) rash, (-) lumps, (-) itching, (-) dryness, (-) acne, (-) discoloration, (-) recurrent skin infections, (-) changes in hair, nails or moles.

Respiratory: (-) cough, (-) hemoptysis, (-) cyanosis, (-) wheezing, (-) nocturnal choking or gasping.

Cardiovascular: (-) chest pain, (-) dizziness, (-) dyspnea with exertion, (-) edema, (-) high blood pressure, (-) irregular heartbeat, (-) orthopnea, (-) palpitations, (-) paroxysmal nocturnal dyspnea, (-) shortness of breath, (-) Syncope.
Cardiovascular:
Gastrointestinal: (-) abdominal pain, (-) heartburn, (-) constipation, (-) diarrhea, (-) nausea, (-) vomiting, (-) hematochezia, (-) melena, (-) change in bowel habits.

Musculoskeletal: (-) muscle pain, (-) joint pain, (-) bone pain.

Peripheral Vascular: (-) intermittent claudication, (-) cramps, (-) varicose veins, (-) thrombophlebitis.

Neurological: (-) numbness, (-) tingling, (-) tremors, (-) seizures, (-) vertigo, (-) memory loss, (-) any focal or diffuse neurological deficits.

Endocrine: (-) heat or cold intolerance, (-) excessive sweating, (-) excessive thirst, (-) excessive hunger, (-) excessive urination, (-) hirsutism, (-) change in ring or shoe size.

Hematologic/Lymphatic: (-) anemia, (-) easy bruising, (-) excessive bleeding, (-) history of blood transfusions.

PHYSICAL EXAM:
Vitals:
BP: 113/65(Left Arm)(Standing)
Pulse: 53(Left brachial)(Standing)(Regular)

Weight: 195 lbs
Height: 5′ 8″
BMI: 29.65
BSA: 2.06
BP: 116/66(Left Arm)(Supine)
Pulse: 47(Left brachial)(Supine)(Regular)

General Appearance: The patient is an extremely pleasant 63 year old male who looks younger than his stated age. is well developed and well nourished in no apparent distress. His body habitus is overweight, his mood is normal.
HEENT: Normocephalic and atraumatic. Pupils are equally round and reactive to light and accommodation. Extraocular muscles are intact. Left corneal opacification. Patient’s neck is supple with no jugular venous distention, left carotid bruit was heard and carotid pulses are +2/2. Normal carotid artery upstroke bilaterally. Palpation is not painful and no thyromegaly nor lymphadenopathy can be appreciated.
Respiratory: Clear to auscultation bilaterally without wheezes or rhonchi. No intercostal retractions or accessory muscle use were noted.
Cardiovascular: Normal sinus bradycardia. Cardiac point of maximal impulse at left fifth intercostal space mid-clavicular line. Normal S1, S2 with physiologic splitting of S2. No murmurs, thrills, rubs, gallops, or clicks were heard.
Gastroenterology: Abdomen is soft non-tender and non-distended. Positive bowel sounds, no hepatomegaly or splenomegaly was noted. No bruits were heard.
Extremities: Pulses were 2+ throughout bilaterally. No cyanosis, edema or clubbing.
Musculoskeletal: Motor strength is appropriately intact throughout bilaterally.
Neurologic: Patient is alert and oriented x3 with deep tendon reflexes appropriately intact throughout bilaterally, non-focal.
Psychiatric: Patient is conscious, cooperative, and well-oriented to time, place, and person. There are no mood swings or psychotic features. Patient’s insight is good. Memory and judgement are intact.
Skin: No skin rash, subcutaneous nodules, lesions or ulcers observed.
DIAGNOSTIC DATA:

ELECTROCARDIOGRAM: Date performed: Apr 1, 2016.
Indication: Palpitations, shortness of breath.
Interpretation: Rate: 62 bpm; Rhythm: Atrial fibrillation, occasional VPC’s vs aberrantly conducted beats and low voltage limb leads.
Conclusion: Abnormal ECG.

2D COLOR DOPPLER ECHOCARDIOGRAPHY:
Date: Feb 2, 2016 Indication: Occasional shortness of breath, Abnormal EKG, H/O severe CAD s/p PCI s/p MI, Difficult to control blood pressure.

Findings:
Left atrium: Dimension: 4.7 cm. (Men: 3-4 cm/Women: 2.7-3.8 cm). It is mildly dilated.
Left ventricle:
-LVIDd = 5.1 cm (Men:4.2-5.9 cm/Women: 3.9-5.3cm).
-LVIDs = 3.7 cm (2.0-4.1 cm).
-IVS = 1.3 cm (0.6-1.1 cm).
-LVPWd = 1.2 cm (0.6-1.1 cm).
Ventricular thickness: There is moderate LV concentric hypertrophy.

Right atrium: Normal in size and shape and shows no signs of ASD, mass or thrombus.
Right ventricle: RVSP: 42 mmHg (15-25 mmHg). Increased right ventricular pressure.

Aortic valve: Peak Velocity = 1.5 m/sec (1.0 – 1.7 m/sec). Trace insufficiency. No sclerosis. No stenosis. Normal trileaflet aortic valve.
Mitral valve: Mild regurgitation with posteriorly-directed jet. No sclerosis. No stenosis. No valve prolapse.
Tricuspid valve: Mild regurgitation. No sclerosis. No stenosis. No vegetations noted.
Pulmonic valve: Normal pulmonic valve.
Aorta: Ascending aorta: 3.3 cm. ( 2.1-3.4 cm).

Left ventricle ejection fraction: 60 %.

Pericardium: No effusion or calcification.
Venous: Inferior vena cava: Normal diameter with normal respiratory variation.

TREADMILL STRESS TEST/W STRESS ECHOCARDIOGRAPHY.
Date: Feb 4, 2016. Indication: Occasional shortness of breath, Abnormal EKG, History of severe CAD, S/p PCI
Risk and benefits of exercise stress test including but not limited to myocardial infarction, vascular compromise and death were explained to Mr. SHPIZEAR in detail. The patient asked appropriate questions. All questions were answered. The patient wished to proceed and gave his informed consent.

Protocol: Standard Bruce protocol.

Procedure:
STAGE I (Min 0 to 2:50): Min: 2 . MPH: 1.7. Grade: 10 %. MET: 1-5. BP: 138/85, Pulse: 119, O2 Sat: 99 (Room air).
STAGE II (Min 3 to 5:50): Min: 5 . MPH: 2.5. Grade: 12%. MET: 6-7. BP: 145/85, Pulse: 132, O2 Sat: 97 (Room air).

Results:
Maximal Predicted Heart Rate: 158 bpm.
Peak heart rate achieved: 152 bpm.
Maximal heart rate achieved: 96 % of predicted heart rate.
Average O2 saturation throughout the study: 99 %.
Total Minutes: 6.15.
Reason for stopping: Generalized fatigue.

Clinical response:
Peak exercise electrocardiogram revealed no significant ischemic changes and no significant arrhythmias.

Stress echocardiography:

Findings:
Left atrium: Dimension: 4.7 cm. (Men: 3-4 cm/Women: 2.7-3.8 cm). It is moderately dilated.
Left ventricle:
-IVS = 1.3 cm (0.6-1.1 cm).
-LVPWd = 1.2 cm (0.6-1.1 cm).
Ventricular thickness: There is moderate LV concentric hypertrophy.

Right atrium: Normal in size and shape and shows no signs of ASD, mass or thrombus.
Right ventricle: Normal in size and shape and shows no signs of VSD, mass or thrombus.

Left ventricle ejection fraction: 60 %.

Pericardium: No effusion or calcification.
Venous: Inferior vena cava: Normal diameter with normal respiratory variation.

Summary: The patient exercised according to the BRUCE protocol for a total of 6.15 minutes, achieving a peak heart rate of 152 bpm, 96% of the maximum predicted heart rate. Electrocardiogram showed no significant ST-T changes. Atrial premature contractions/ventricular premature contractions/dysrhythmias were not seen.
Blood pressure response to exercise was normal at 145/85 mmHg.
Symptoms at peak exercise: generalized fatigue.
The study was inconclusive.

Conclusion:
Response to exercise: Stress testing performed today was inconclusive given that the target exercise time duration was not achieved that the maximal target heart rate was not achieved.
There is no evidence of inducible ischemia at the level of exercise achieved.
No evidence of stress induced arrhythmias at the level of exercise achieved.
The patient had an inadequate exercise capacity.
Probability of obstructive coronary artery disease: Low. It was discussed with the patient that coronary artery disease may be present despite the results of the exercise stress test. Exercise stress testing is only one diagnostic tool and is related to statistical and “pre-test probability”. It may be falsely negative in the presence of significant coronary artery disease. Other diagnostic tests may be in order if new symptoms develop or if symptoms recur or change in quality or duration. The patient was instructed to contact me immediately and contact emergency medical services in this event.

CAROTID ARTERY DUPLEX SCAN:
Date of Study: Feb 26, 2016.
Indication: Left carotid bruit, and history of severe CAD.

Measurements:
Left:
CCA distal peak velocity: 48 cm/sec.
CCA end diastolic velocity: 18 cm/sec.
ICA distal peak velocity: 51 cm/sec.
ICA end diastolic velocity: 25 cm/sec.
ECA distal peak velocity: 70 cm/sec.
ECA end diastolic velocity: 14 cm/sec.
Left vertebral artery showed antegrade flow.
ICA/CCA: 1.1.
Right:
CCA distal peak velocity: 66 cm/sec.
CCA end diastolic velocity: 22 cm/sec.
ICA distal peak velocity: 50 cm/sec.
ICA end diastolic velocity: 22 cm/sec.
ECA distal peak velocity: 85 cm/sec.
ECA end diastolic velocity: 14 cm/sec.
Right vertebral artery showed antegrade flow.
ICA/CCA: 0.8.

Impression/Comments:

Findings: Bilateral minimal plaque.
(2) Vascularized complex nodules seen in the right thyroid gland measuring 1.4cm x 1.0cm x 1.2cm and 0.8cm x 0.6cm x 0.8cm. (1) Complex nodule seen in the left thyroid gland measuring less than 1cm. Recommend follow up with Dr. Nourparvar.

Plan:
Non-obstructive disease.
Will intensify medical therapy.

Follow up:
Follow up with Dr. Nourparvar recommended.

LOWER EXTREMITIES VENOUS DOPPLER: Aug 19, 2010.
Indication: trace bilateral leg edema, h/o shortness of breath.
Impression: Normal venous flow with normal collapse with compression. Normal augmentation of venous flow with calf compression. No evidence of venous insufficiency with valsalva manuever or abdominal pressure. Normal lower extremities.
No evidence of deep venous thrombosis or venous outflow obstruction of the lower extremities by duplex scanning.

RENAL ARTERY-AORTA DUPLEX SCAN: Aug 17, 2010 Indication: Hypertensive heart disease w/o heart failure.

Measurements:
Left Renal Peak Systolic Velocity:
Proximal: 0.79 m/s [<1.0].
Mid: 0.83 m/s [<1.0].
Distal: 0.44 m/s [<1.0].
Renal/Aortic Ratio: 0.8. [<3.5].
Right Renal Peak Systolic Velocity:
Proximal: 0.58 m/s [<1.0].
Mid: 0.6 m/s [<1.0].
Distal: 0.63 m/s [<1.0].
Renal/Aortic Ratio: 0.6. [<3.5].

Aorta:
Proximal Aortic Diameter: 2.2 cm.
Mid Aortic Diameter: 1.8 cm.
Distal Aortic Diameter: 1.4 cm.

Kidney:
Left:
kidney length: 11.6 cm [8.5-15.0 cm].
Kidney Width: 6.1 cm. ( 4.5-5.0 cm].
Kidney Depth (trans): 5 cm. [4.5-5.0].
Cortical Thickness: 1.4 cm. [1.1 cm].
Parenchymal Flow /Waveform:
Upper Early Systolic Peak Present.
Mid Early Systolic Peak Present.
Lower Early Systolic Peak Present.
Resistive Index: 0.63 [<0.75] (PSV-EDV/PSV).

Right:
kidney length: 10.8 cm [8.5-15.0 cm].
Kidney Width: 5.4 cm. ( 4.5-5.0 cm].
Kidney Depth (trans): 5.4 cm. [4.5-5.0].
Cortical Thickness: 2 cm. [1.1 cm].
Parenchymal Flow /Waveform:
Upper Early Systolic Peak Present.
Mid Early Systolic Peak Present.
Lower Early Systolic Peak Present.
Resistive Index: 0.61 [<0.75]
(PSV-EDV/PSV).

Technical impression:
Within normal limits.

1 simple cyst in the left kidney measuring 3.3 cm x 2.6 cm x 2.8 cm. Recommend follow up with Dr. Navon.

ABDOMINAL AORTA DUPLEX SCAN:
Date: Aug 16, 2010 Indication: Indication: Hypertension (401.1).

Aorta:
Proximal Aortic Diameter: 2.3 cm.
Proximal Aortic Peak Systolic Velocity: 1.08 m/s.
Mid Aortic Diameter: 1.6 cm.
Mid Aortic Peak Systolic Velocity: 0.71 m/s.
Distal Aortic Diameter: 1.4 cm.
Distal Aortic Peak Systolic Velocity: 0.95 m/s.

Technical impression:
Within normal limits.
Mild plaque in Abdominal Aorta.

Cardiac Catheterization: CARDIAC CATHETERIZATION. 10/12/2012
– The left main was nonobstructive, had approximately 20% in its mid to distal section.
-Circumflex artery was mildly diseased in its proximal section up to 20%, and 100% chronic total occlusion at its mid section. There was evidence of circumflex-to-circumflex collateral flow.
-The first marginal branch off the circumflex artery had severe disease, was 100% stenotic. It is a small vessel, less than 1.25 mm in diameter.
-The left anterior descending had mild proximal disease of less than 20% and then proximal to mid section had approximately 75% to 80% disease, and mid section had 99% area of disease with severe haziness and TIMI-2 flow in the distal LAD was noted. The first diagonal branch was mildly diseased, less then 30%. The second diagonal branch was small, approximately 1.2 mm in diameter, and had approximately 40% stenosis in its mid section.
– The right coronary artery had a stent in its proximal section, just distal to the ostium. The stent appeared to be well opposed to the right coronary artery. There was no significant in-stent restenosis. Distal to the stent, there was approximately 20% stenosis. The right coronary artery is dominant, and there was evidence of right-to-left/circumflex artery collateral flow.
-LVEDP measured approximately 22-24 mm. LV gram showed apical akinesis, with an ejection fraction of approximately 40% to 45%. Pullback across the aortic valve showed no significant gradient.
-A 2.5 x 12 mm Xience drug-eluting stent was then placed in LAD and dilated in the lesion, it was then advanced and eased across the lesion without difficulty. It was dilated to 9-12 atmospheres of pressure. Post dilatation, there was 0% residual stenosis and TIMI-3
flow. I was concerned about the more proximal lesion in the LAD, and I placed a 0.014 pressure wire in the first lesion across the stent. — A 2.5 x 18 mm Xience drug-eluting stent was placed but not deployed, as it did not cover the entire area of stenosis. It was exchanged for 2.5 x 28 mm Xience prime drug-eluting stent. It was inflated to up to 12 atmospheres of pressure. Post deployment, the area looked good, but appeared to be mildly under deployed.
IMPRESSION:
Status post successful percutaneous coronary intervention, stent placement to the left anterior descending, in patient with acute coronary syndrome.
CARDIAC CATHETERIZATION
Date: 08/25/10
Indication: Patient with recurrent chest pain, h/o CAD
Impression:
1. Unsuccessful circumflex artery vascularization in patient with chronic occlusion. This will be managed medically and we will reassess the need for possible intervention if the patient continues to be symptomatic.
2. S/p fractional flow reserve of the LAD vessel. The lesion was found to be not critically obstructive. The patient’s management including intensification of medical therapy will be performed.

Cardiac Catheterization and Angioplasty: CARDIAC CATHETERIZATION AND PERCUTANEOUS CORONARY INTERVENTION WITH STENT PLACEMENT
Date: 08/18/2010
Indication: Recurrent angina, positive exercise stress test.
Description: The left main was not obstructed. The circumflex artery was mildly diseased in the proximal section and appeared to be totally occluded in the mid to distal section. There was evidence of left to right collaterals. The left anterior descending had mild disease in its proximal section, was diffusely diseased in the mid section, and had approximately 70% disease in the mid section of the LAD. The 1st diagonal vessel was approximately 1.75 mm and had no significant disease. The 2nd diagonal vessel was approximately 1 mm and was approximately 60% diseased in its proximal section. Angiography revealed 99% occlusion in the right coronary artery proximal section, with evidence of collateral flow to the mid right coronary artery. There was evidence of right to left collaterals, especially during the marginal branches off the circumflex vessel. LVEDP measured 9 mmHg. The LV-gram showed a mild area of mid diaphragmatic hypokinesis, otherwise reasonably preserved LV function with an
ejection fraction of approximately 50%.
Impression:
1. Status post left heart cardiac catheterization, LV angiography and selective
bilateral renal angiography.
2. Status post right coronary artery atherectomy.
3. Percutaneous coronary intervention balloon dilatation.

CT of the Chest: PET/CT, whole body. 08/17/10
Indication: Left lung nodule
Finding:
1. A depressed mid sternal fracture is noted, with associated metabolic activity, or inflammation.
2. 1.5 cm left upper lobe non-metabolically active nodule is most likely a hamartoma. A second left lung nodule, measuring 5 mm within left posterior costophrenic sulcus may represent another hamartoma, also not metabolically active. I have discussed the findings with Dr. Rubenstein-the finding s are benign, no need to be followed further.
3. Fatty liver
4. 3 cm left renal cyst
5. Vascular and coronary artery calcifications.

Thyroid Ultrasound: Date: Feb 19, 2016.
Indication: History of thyroid nodules.
Impression: The study shows two complex nodules with vascularity seen in the right thyroid gland measuring 1.4cm x 1.2cm x 1.2cm and 0.9cm x 0.8cm x 0.8. One complex nodule with vascularity seen in the left thyroid gland measuring 0.9cm x 0.8cm x 0.8cm.
Plan: Follow up with Dr. Nourparvar is recommended.
Comments: No change compared with previous study.

Other: THYROID ULTRASOUND
Date: 10/23/2012
Indication: H/O Thyroid nodules
Impression: Bilateral multiple complex nodules with vascularity measuring less than 1cm. No change compared with previous study.
Comments: Recommend follow up with Dr. Nourparvar.

Colonoscopy: No colonoscopy has ever been performed.
Prostate exam: No urological exam has ever been performed.
PSA level: 0.6 ng/mL on Jan 26, 2016.
FLU VACCINATION: 2012.

————————————————————————————————————————————————————
DIAGNOSIS/ASSESSMENT:

HIGH RISK, NON COMPLIANT PATIENT.

LEG EDEMA.
Improved with diuretic therapy. Will consider lower extremity venous Duplex scan if this symptom persists. The patient was advised to elevate his legs above heart level for 15-20 minutes 3-4 times per day as needed. Low salt diet advised.

H/O PALPITATIONS.
H/O PERSISTENT ATRIAL FIBRILLATION.
S/p comprehensive electrophysiology study on 04/06/16 and wide antral pulmonary vein isolation, additional GP modification, entire posterior wall ablation, entire roof and posterior roof ablation, ridge and ligament of Marshall ablation, septal ablation. The patient is currently in normal sinus rhythm. Restart Pradaxa 150 mg PO BID. The importance of taking Pradaxa twice a day and not missing a dose was stressed to the patient, and the patient agreed and was able to repeat back instructions for Pradaxa dosing twice a day. He was advised to avoid alcohol, caffeine, and other stimulants, which may precipitate this symptom. He was instructed to monitor his pulse rate at home and contact me immediately if he notices any irregularities or develops symptoms.

CORONARY ARTERY DISEASE.
The patient is status post multiple coronary interventions. Cardiac catheterization 10/12/12 indicated subtotal occlusion of the left anterior descending in the mid section that was stented. The patient is on Pradaxa and statin therapy. He was advised of the importance of cardiac risk factor modification, including optimal blood pressure, lipid profile, a healthy diet, and daily aerobic exercise. He may need another cardiac catheterization. Will continue to follow him closely.

HYPERTENSIVE HEART DISEASE W/O CHF.
Moderate concentric left ventricular hypertrophy per echocardiography. No evidence of renal artery stenosis or abdominal aortic aneurysm per Duplex scan today. Strongly recommend a low salt diet and increasing his exercise program. Optimal blood pressure, with target SBP of 110-120mmHg advised.

HYPERLIPIDEMIA.
LDL 80 mg/dL, HDL 60 mg/dL, triglycerides 75 mg/dL on 01/26/16. The patient is on Pravachol. Low fat diet advised. Weight loss was advised.

DIABETES MELLITUS TYPE II.
FBS 91 mg/dL on 04/01/16. Low carbohydrate, healthy diet advised.

H/O THYROID NODULES.
2 vascularized complex nodules in the right thyroid gland, and one complex nodule in the left thyroid gland on ultrasound on 2/26/2016. No changes compared with prior studies. Recommend follow up with Dr. Nourparvar.

OTHER:
1. Left perihilar lung nodule PET/CT on 08/17/10. The findings are benign, and there is no need for further evaluation per Dr. Rubenstein.
2. Incidental finding of 1 simple cyst in the left kidney per ultrasound. Recommend follow-up with Dr. Navon.
3. Thrombocytopenia. Platelet count 122 thou/L on 04/01/16. Will follow with serial labs and consider referral to a hematologist if it does not improve.
4. Mild renal insufficiency. BUN 12 mg/dL and Cr 1.22 mg/dL on 04/01/16. Will follow with serial labs.
PLAN:
Medication changes: No.

Laboratory: Lipid panel, Chem 24, LFTs, TSH, HbA1c.

Diet: Patient advised to follow a healthy low fat, salt and carbohydrate diet.

Exercise recommendations: Regular exercise is strongly recommended. Recommend gradual increase in daily aerobic exercise.

Hypertension Instructions: The patient was instructed to monitor their blood pressure twice daily and provide me with the records.

Anticoagulation/ Anti-thrombin recommendations: The patient was advised that chronic anticoagulation/anti-thrombin therapy is recommended for his heart condition. Risks of chronic anticoagulation/anti-thrombin therapy include, but are not limited to, increased risk of bleeding complications including the possibility of intracranial bleeding, and increased risk of bleeding related to trauma. Given the patient’s increased risk for thromboembolic events, anti-thrombin therapy is recommended. Careful monitoring is extremely important. If, during anticoagulation/anti-thrombin therapy, the patient notices any evidence of bleeding or the patient is involved in a traumatic accident, the patient was advised to please notify my office immediately.

Preventive Medicine: It is important that the patient follow up with their primary physician for preventative medicine follow ups including yearly prostate exam and annual physical exam.

Follow Up: The patient was advised to return to the office for follow up in 1 week or earlier if he has any medical problems.

Emergency recommendations: The patient was advised to call 911 or go to the emergency room if the patient’s condition worsens or does not improve.

——————————————————————————————————————————————————-
Changed/Discontinued Medication(s):
Discontinued By Other MD: EDARBI 40 MG TABLET
Check in time: 07:03 AM Check out time: 07:27 AM

Electronically signed: 07/06/2016 09:56 AM BENZUR, URI

99213 Office/outpatient visit, est, mod

Uri M. Ben-Zur, M.D., F.A.C.C.
Interventional Cardiology / Invasive Electrophysiology

18200 Ventura Blvd
Tarzana, CA 91356
Phone (818) 986-0911 Fax (818) 986-9301
Date of visit: 07/05/2016
Reason for Visit:
Requesting Physician:
I had the opportunity to evaluate on the date stated above. I have reviewed the past medical history, symptoms and current therapy. In addition, I have examined the patient and based on my findings have provided my overall impression, outlining my treatment and plans in the summary below.

CHIEF COMPLAINT /HISTORY OF PRESENT ILLNESS:

Mr. DENNIS KENNELLY is an extremely pleasant 67 year old male with a past medical history of paroxysmal atrial fibrillation, and hypertension.

The patient is being seen frequently given fluctuating blood pressures and multiple medication adjustments.

The patient has history of occasional shortness of breath with moderate exertion. This symptom has existed for an extended period of time. It is mild in severity, and has not changed. No associated symptoms noted.

The patient denies chest pain, palpitations, dizziness, syncope.

He does not monitor his blood pressure at home. Mr. KENNELLY is following an exercise program. He is walking 90 minutes for 4 days a week. He follows a healthy diet. He has been increasing his salad and vegetable intake, has cut out sugar and salt, and limits his fats.

At the time of his last visit, no medication changes were made.

Overal states that he is stable.
PAST MEDICAL HISTORY:
Cardiovascular:
Atrial Fibrillation.
Cardiomyopathy, non ischemic.
Congestive Heart Failure.
Deep Vein Thrombosis. 03/2016, left leg.
Hypertension, benign essential.
Musculoskeletal:
Osteoarthritis.
Psychiatry:
Alcoholism.
Depression.
Skin:
Psoriasis.
Skin cancer, s/p excision.
SURGICAL HISTORY:
Cardiac catheterization 1989 revealed normal coronary arteries.
Left hand tendon repair.
Surgery for pyloric stenosis at 3 weeks old.

CURRENT MEDICATIONS:
1 Trazodone 150 Mg Tablet SIG: Take 1 PO QHS
2 Vitamin B-1 100 Mg Tablet SIG: Take 1 by mouth three times a day
3 Klor-con M10 Tablet Meq SIG: one po qd
4 Xarelto 20 Mg Tablet SIG: 1 tablet PO QD
5 Bystolic 10 Mg Tablet SIG: one tab po qd
6 Antabuse 250 Mg Tablet SIG: Take 1 tab by mouth once daily
7 Edarbi 80 Mg Tablet SIG: Take 1 tab by mouth once daily
8 Digoxin 250 Mcg Tablet SIG: take 1 tab PO QD
9 Lasix 20 Mg Tablet SIG: one tab po qd
10 Lisinopril 10 Mg Tablet SIG: Take 1 tab by mouth once daily
11 Metoprolol Succ Er 100 Mg Tab SIG: Take 1 by mouth twice daily
12 Vitamin B-1 100 Mg Tablet SIG: one tab po tid

ALLERGIES / INTOLERANCES:
No Known Drug Allergy

SOCIAL HISTORY:
Marital Status: The patient is widowed. He has 2 healthy children.
Smoking/tobacco use: Discontinued 07/2015. He smoked one pack of cigarettes a day and 1-4 cigars/day for several years.
Alcohol: He is an alcoholic. He has been in and out of rehab for several years.
Recreational drug use: He denies recreational drug use.
Caffeine Intake: 2-3 large cups of coffee/day.
Stress Level: Moderate.
Occupation: Entertainment and employment lawyer.

FAMILY HISTORY:
Father is deceased. He died at the age of 87 due to Merkel cell cancer. H/o hypertension.
Mother is deceased. She died at the age of 61 due to colorectal cancer.
1 sister, alive and healthy.
REVIEW OF SYSTEMS:
Constitutional Symptoms: (-) fever, (-) chills, (-) night sweats, (-) fatigue, (-) weakness, (-) changes in appetite or weight.

Integumentary: (-) rash, (-) lumps, (-) itching, (-) dryness, (-) acne, (-) discoloration, (-) recurrent skin infections, (-) changes in hair, nails or moles.

Ears, Nose, Mouth, Throat: (-) hearing changes, (-) tinnitus, (-) vertigo, (-) dizziness, (-) earache, (-) ear infection, (-) ear discharge, (-) use of hearing aids.

Respiratory: (-) cough, (-) hemoptysis, (-) cyanosis, (-) wheezing, (-) nocturnal choking or gasping.

Cardiovascular: (-) chest pain, (-) dizziness, (-) dyspnea with exertion, (-) edema, (-) high blood pressure, (-) irregular heartbeat, (-) orthopnea, (-) palpitations, (-) paroxysmal nocturnal dyspnea, (+) shortness of breath, (-) Syncope.
Cardiovascular: (+) shortness of breath.
Gastrointestinal: (-) abdominal pain, (-) heartburn, (-) constipation, (-) diarrhea, (-) nausea, (-) vomiting, (-) hematochezia, (-) melena, (-) change in bowel habits.

Genitourinary: (-) dysuria, (-) frequency, (-) urgency, (-) hesitancy, (-) polyuria, (-) nocturia, (-) hematuria, (-) urinary incontinence, (-) flank pain, (-) change in urinary habits.

Musculoskeletal: (-) muscle pain, (-) joint pain, (-) bone pain.

Peripheral Vascular: (-) intermittent claudication, (-) cramps, (-) varicose veins, (-) thrombophlebitis.

Neurological: (-) numbness, (-) tingling, (-) tremors, (-) seizures, (-) vertigo, (-) memory loss, (-) any focal or diffuse neurological deficits.

Endocrine: (-) heat or cold intolerance, (-) excessive sweating, (-) excessive thirst, (-) excessive hunger, (-) excessive urination, (-) hirsutism, (-) change in ring or shoe size.

Hematologic/Lymphatic: (-) anemia, (-) easy bruising, (-) excessive bleeding, (-) history of blood transfusions.

PHYSICAL EXAM:
Vitals:
BP: 113/75(Left Arm)(Standing)
Pulse: 59(Left brachial)(Standing)(Irregularly irregular)

Weight: 205 lbs
Height: 5′ 8.5″
BMI: 30.71
BSA: 2.12
BP: 118/73(Left Arm)(Supine)
Pulse: 89(Left brachial)(Supine)(Irregularly irregular)

General Appearance: The patient is an extremely pleasant 67 year old male who looks younger than his stated age. is well developed and well nourished in no apparent distress. His body habitus is obese. His mood is normal.
HEENT: Normocephalic and atraumatic. Pupils are equally round and reactive to light and accommodation. Extraocular muscles are intact. Patient’s neck is supple with no jugular venous distention, no carotid bruit was heard and carotid pulses are +2/2. Normal carotid artery upstroke bilaterally. Palpation is not painful and no thyromegaly nor lymphadenopathy can be appreciated.
Respiratory: Clear to auscultation bilaterally without wheezes or rhonchi. No intercostal retractions or accessory muscle use were noted.
Cardiovascular: Irregular heart rate and irregular rhythm. Cardiac point of maximal impulse at left fifth intercostal space mid-clavicular line. Normal S1, S2 with physiologic splitting of S2. No murmurs, thrills, rubs, gallops, or clicks were heard.
Gastroenterology: Abdomen is soft non-tender and non-distended. Positive bowel sounds, no hepatomegaly or splenomegaly was noted. No bruits were heard.
Extremities: Pulses were 2+ throughout bilaterally. +1 pitting edema to the bilateral lower extremities, slightly worse on the left and accompanied by mild erythema on the left.
Musculoskeletal: Motor strength is appropriately intact throughout bilaterally.
Neurologic: Patient is alert and oriented x3 with deep tendon reflexes appropriately intact throughout bilaterally, non-focal.
Psychiatric: Patient is conscious, cooperative, and well-oriented to time, place, and person. There are no mood swings or psychotic features. Patient’s insight is good. Memory and judgement are intact.
Skin: No skin rash, subcutaneous nodules, lesions or ulcers observed.
DIAGNOSTIC DATA:

ELECTROCARDIOGRAM: Date performed: Apr 5, 2016.
Indication: Occasional shortness of breath.
Interpretation: Rhythm: A Fib 76bpm and intraventricular conduction delay; Axis: Left axis deviation; Left Ventricular Hypertrophy.

2D COLOR DOPPLER ECHOCARDIOGRAPHY:
Date: Apr 5, 2016 Indication: Occasional shortness of breath, Abnormal EKG, H/O DVT.

Findings:
Left atrium: Dimension: 4.8 cm. (Men: 3-4 cm/Women: 2.7-3.8 cm). It is mildly dilated.
Left ventricle:
-LVIDd = 5.1 cm (Men:4.2-5.9 cm/Women: 3.9-5.3cm).
-LVIDs = 3.4 cm (2.0-4.1 cm).
-IVS = 1 cm (0.6-1.1 cm).
-LVPWd = 0.8 cm (0.6-1.1 cm).

Right atrium: Normal in size and shape and shows no signs of ASD, mass or thrombus.
Right ventricle: RVSP: 26 mmHg (15-25 mmHg).

Left ventricle ejection fraction: 50-55%.

Pericardium: No effusion or calcification.
Venous: Inferior vena cava: Normal diameter with normal respiratory variation.
Other: Mildly reduced global left ventricle function. May benefit from AFib ablation/DCCV.

TREADMILL STRESS TEST/W STRESS ECHOCARDIOGRAPHY.
Date: Aug 13, 2015. Indication: Occasional shortness of breath, H/o CHF, Abnormal EKG
Risk and benefits of exercise stress test including but not limited to myocardial infarction, vascular compromise and death were explained to Mr. KENNELLY in detail. The patient asked appropriate questions. All questions were answered. The patient wished to proceed and gave his informed consent.

Protocol: Standard Bruce protocol.

Procedure:
STAGE I (Min 0 to 2:50): Min: 2 . MPH: 1.7. Grade: 10 %. MET: 1-5. BP: 138/82, Pulse: 90, O2 Sat: 95.
STAGE II (Min 3 to 5:50): Min: 5 . MPH: 2.5. Grade: 12%. MET: 6-7. BP: 142/85, Pulse: 103, O2 Sat: 95.

Results:
Maximal Predicted Heart Rate: 153 bpm.
Peak heart rate achieved: 130 bpm.
Maximal heart rate achieved: 84 % of predicted heart rate.
Average O2 saturation throughout the study: 95 %.
Total Minutes: 8.
Reason for stopping: Generalized fatigue.

Clinical response:
Peak exercise electrocardiogram revealed no significant ischemic changes and occasional VPCs.

Stress echocardiography:
Revealed normal left ventricular function at rest with an adequate increase in left ventricular function in response to exercise.

Findings:
1. Normal right heart size and function
2. Left atrium 4.8 cm (moderately dilated)
3. IVS 1.4 cm, PW 1.4 cm. Moderate LVH. Left ventricular ejection fraction is normal at 50-55%.
4. Global systolic function normal.
5. Normal valvular structure.
6. No pericardial effusion.
7. Ascedning aorta 3.9 cm.

Summary: The patient exercised according to the BRUCE protocol for a total of 8 minutes, achieving a peak heart rate of 130 bpm, 84% of the maximum predicted heart rate. Electrocardiogram showed no significant ST-T changes. Dysrrhythmias were seen as mentioned above.
Symptoms at peak exercise: generalized fatigue.
The study was inconclusive.

Recommendations: Given test results and high pretest probability, recommend adenosine stress test at patient’s earliest convenience. The patient agrees. The study will be scheduled at the earliest convenience.

Holter Monitoring 24hrs: Hookup Date: Jul 23, 2015..
Indication: evaluation of atrial fibrillation.
Findings:
Occasional RVR at up to 197bpm.

CAROTID ARTERY DUPLEX SCAN:
Date of Study: Jul 27, 2015.
Indication: Left carotid bruit, H/O non Ischemic Cardiomyopathy.

Measurements:
Left:
CCA distal peak velocity: 61 cm/sec.
CCA end diastolic velocity: 20 cm/sec.
ICA distal peak velocity: 87 cm/sec.
ICA end diastolic velocity: 35 cm/sec.
ECA distal peak velocity: 76 cm/sec.
ECA end diastolic velocity: 22 cm/sec.
Left vertebral artery showed antegrade flow.
ICA/CCA: 1.4.
Right:
CCA distal peak velocity: 75 cm/sec.
CCA end diastolic velocity: 22 cm/sec.
ICA distal peak velocity: 75 cm/sec.
ICA end diastolic velocity: 36 cm/sec.
ECA distal peak velocity: 99 cm/sec.
ECA end diastolic velocity: 25 cm/sec.
Right vertebral artery showed antegrade flow.
ICA/CCA: 1.

Impression/Comments:

Findings: Bilateral mild plaque.

Plan:
Non-obstructive disease.
Will intensify medical therapy.

LOWER EXTREMITIES VENOUS DOPPLER: Apr 5, 2016.
Indication: 2+ bilateral leg edema.
Impression: Positive DVT seen in the left SFV distal. No augmentation seen and non-compressible distal left SFV veins.

RENAL ARTERY-AORTA DUPLEX SCAN: Aug 9, 2015.
Indication: Uncontrolled hypertensive heart disease without heart failure (402.00).

Measurements:
Left Renal Peak Systolic Velocity:
Proximal: 0.78 m/s [<1.0].
Mid: 0.6 m/s [<1.0].
Distal: 0.66 m/s [<1.0].
Renal/Aortic Ratio: 1. [<3.5].
Right Renal Peak Systolic Velocity:
Proximal: 0.73 m/s [<1.0].
Mid: 0.77 m/s [<1.0].
Distal: 1.08 m/s [<1.0].
Renal/Aortic Ratio: 1.4. [<3.5].

Aorta:
Proximal Aortic Diameter: 2.4 cm.
Mid Aortic Diameter: 1.6 cm.
Distal Aortic Diameter: 1.2 cm.
Aortic Peak Systolic Velocity: 0.79 m/s.

Kidney:
Left:
kidney length: 11.7 cm [8.5-15.0 cm].
Kidney Width: 7 cm. ( 4.5-5.0 cm].
Kidney Depth (trans): 5 cm. [4.5-5.0].
Cortical Thickness: 1.5 cm. [1.1 cm].
Parenchymal Flow /Waveform:
Upper Early Systolic Peak Present.
Mid Early Systolic Peak Present.
Lower Early Systolic Peak Present.
Resistive Index: 0.68 [<0.75] (PSV-EDV/PSV).

Right:
kidney length: 10 cm [8.5-15.0 cm].
Kidney Width: 5.4 cm. ( 4.5-5.0 cm].
Kidney Depth (trans): 4.9 cm. [4.5-5.0].
Cortical Thickness: 1.2 cm. [1.1 cm].
Parenchymal Flow /Waveform:
Upper Early Systolic Peak Present.
Mid Early Systolic Peak Present.
Lower Early Systolic Peak Present.
Resistive Index: 0.57 [<0.75]
(PSV-EDV/PSV).

Technical impression:
Within normal limits.

ABDOMINAL AORTA DUPLEX SCAN:
Date: Aug 6, 2015 Indication: Indication: Atherosclerosis of the Aorta (440.0).

Aorta:
Proximal Aortic Diameter: 2 cm.
Proximal Aortic Peak Systolic Velocity: 0.82 m/s.
Mid Aortic Diameter: 1.6 cm.
Mid Aortic Peak Systolic Velocity: 0.79 m/s.
Distal Aortic Diameter: 1.4 cm.
Distal Aortic Peak Systolic Velocity: 0.86 m/s.

Technical impression:
Within normal limits.
Minimal plaque seen in abdominal aorta.

————————————————————————————————————————————————————
DIAGNOSIS/ASSESSMENT:

COMPLEX, HIGH RISK PATIENT.

HYPERTENSION.
Moderate concentric left ventricular hypertrophy per echocardiography. No evidence of renal artery stenosis or abdominal aortic aneurysm per Duplex scan. Recommend that the patient monitor his blood pressure twice daily and provide me with the records. Target systolic blood pressure in the 110-120 mmHg range recommended. Continue medications as prescribed. Low salt, healthy diet and daily aerobic exercise advised.

DYSPNEA.
Mild. Multifactorial. EKG showed AFib at 76 bpm and intraventricular conduction delay, left axis deviation, and LVH. Stress testing was inconclusive. However, there was no evidence of inducible ischemia at the level of exercise achieved. EF at 50-55% per echo. Given test results and high pretest probability, recommend adenosine stress test at patient’s earliest convenience. Patient agrees. The patient was advised of the importance of following a healthy diet, weight loss and daily aerobic exercise. He was instructed to contact me if he develops any other symptoms or decreased exercise tolerance.

H/O PAROXYSMAL ATRIAL FIBRILLATION.
MODERATELY DILATED LEFT ATRIUM.
EKG showed AFib at 76 bpm and intraventricular conduction delay, left axis deviation, and LVH. Occasional VPCs per EST. Continue current medications. The patient was advised to avoid alcohol, caffeine, and other stimulants, which may precipitate his condition.

H/O ELEVATED D-DIMER.
Laboratory results from 4/4/16 revealed elevated D-Dimer at 2.25 mcg/mL FEU. Likely non specific. CT pulmonary arteriography on 07/24/15 ruled out pulmonary embolism.

OTHER:
– DVT. Initially diagnosed during hospital stay at Scottsdale Healthcare. Lower extremity venous doppler on 4/5/16 is positive for DVT in left SFV distally. The patient was instructed to never stop Xarelto unless given written instructions by me.
– Colonoscopy – Patient was referred to Dr. Toomari regarding scheduling a colonoscopy.
– Osteoarthritis. I do not recommend taking Ibuprofen given that he is on Xarelto.
– Depression. Defer management to his psychiatrist.
– ETOH abuse. The patient has been counseled multilple times regarding stopping his alcohol use. However, the patient continues to be non-compliant.

DISCUSSION:

PLAN:
Medication changes: No.

Laboratory: Chem 24, TSH, T3/T4, D-dimer level, PSA.

Procedures to be scheduled: Optimize patient’s medications.

Diet: Patient advised to follow a healthy low fat, salt and carbohydrate diet.

Exercise recommendations: Regular exercise is strongly recommended. Recommend gradual increase in daily aerobic exercise.

Hypertension Instructions: The patient was instructed to monitor their blood pressure twice daily and provide me with the records.

Preventive Medicine: It is important that the patient follow up with their primary physician for preventative medicine follow ups including yearly prostate exam and annual physical exam.

Follow Up: The patient was advised to return to the office for follow up in 1 week or earlier if he has any medical problems.

Emergency recommendations: The patient was advised to call 911 or go to the emergency room if the patient’s condition worsens or does not improve.

——————————————————————————————————————————————————-

Check in time: 07:24 AM Check out time: 08:02 AM

Electronically signed: 07/06/2016 10:16 AM BENZUR, URI

G8427 Med.with dosage and verification documented; 1036F CURRENT TOBACCO NON-USER CAD CAP COPD PV DM; 99213 Office/outpatient visit, est, mod; G8419 BMI abnormal. No followup plan documented

Uri M. Ben-Zur, M.D., F.A.C.C.
Interventional Cardiology / Invasive Electrophysiology

18200 Ventura Blvd
Tarzana, CA 91356
Phone (818) 986-0911 Fax (818) 986-9301
Date of visit: 07/05/2016
Reason for Visit:
Requesting Physician:
I had the opportunity to evaluate on the date stated above. I have reviewed the past medical history, symptoms and current therapy. In addition, I have examined the patient and based on my findings have provided my overall impression, outlining my treatment and plans in the summary below.

CHIEF COMPLAINT /HISTORY OF PRESENT ILLNESS:

is an extremely pleasant 83 year old male with a past medical history of atrial flutter, S/P successful atrial flutter ablation on 12/03/2008, persistent atrial fibrillation, S/P permanent pacemaker implantation for symptomatic bradycardia with first degree atrioventricular block and right bundle branch block on 04/07/2006. He is status post pacemaker pulse generator replacement on 04/17/13. He is accompanied today by his wife, Inna.

The patient complains of shortness of breath with exertion. He can walk 50-100 meters before developing shortness of breath. This symptom has existed for an extended period of time. It is mild to moderate in severity and get worse over the past 1-2 weeks. Associated symptoms include mild to moderate leg edema and productive cough.

The patient denies chest pain, palpitations., dizziness, syncope.

His systolic blood pressure readings have been elevated according to his home monitor, averaging 160 mmHg. The patient does not follow an exercise program. He does not follow a specific diet.

At the time of his last visit, no medication changes were made.
PAST MEDICAL HISTORY:
Cardiovascular:
Atrial Flutter. S/P atrial flutter ablation, 12/2008.
Dyslipidemia.
Hypertensive heart disease without CHF, controlled.
Sick Sinus Syndrome. S/P permanent pacemaker implantation 04/07/06, given symptomatic bradycardia with first degree AV block.
Gastroenterology:
Gastritis.
Gastroesophageal Reflux.
Peptic Ulcer Disease.
Musculoskeletal:
Back Pain.
Knee pain/ h/o injury.
SURGICAL HISTORY:
S/P successful atrial flutter ablation on 12/03/2008
Cataract surgery in 2004
Permanent pacemaker implantation given symptomatic bradycardia with first degree atrioventricular block and right bundle branch block performed on 04/07/2006
S/p pacemaker pulse generator replacement on 04/17/13.

CURRENT MEDICATIONS:
1 Allopurinol 100 Mg Tablet SIG: Take 1 tab by mouth twice daily
2 Linzess 145 Mcg Capsule SIG: take one daily
3 Toprol Xl 25 Mg Tablet SIG: Take one tablet twice daily, hold if sBP is less than 120 mmHg
4 Benicar 20 Mg Tablet SIG: one po qd prn BP>150 mmHg
5 Flomax 0.4 Mg Capsule SIG: one po qd
6 Namenda 10 Mg Tablet SIG: one po qd
7 Furosemide 40 Mg Tablet SIG: Take 1 TAB PO QD
8 Pradaxa 150 Mg Capsule SIG: Take 1 by mouth twice daily

ALLERGIES / INTOLERANCES:
Crestor, Metolazone

SOCIAL HISTORY:
Marital Status: The patient is married.
Smoking/tobacco use: No history of smoking.
Alcohol: The patient occasionally drinks alcoholic beverages.
Caffeine Intake: Drinks coffee 2 times a week.
Occupation: Retired.
Exercise: The patient does not do any form of exercise.

FAMILY HISTORY:
The patient’s father is deceased. He died at the age of 75 due to stomach cancer.
The patient’s mother is deceased. She died at the age of 74 due to heart disease.
REVIEW OF SYSTEMS:
Constitutional Symptoms: (-) fever, (-) chills, (-) night sweats, (-) fatigue, (-) weakness, (-) changes in appetite or weight.

Integumentary: (-) rash, (-) lumps, (-) itching, (-) dryness, (-) acne, (-) discoloration, (-) recurrent skin infections, (-) changes in hair, nails or moles.

Respiratory: (+) wheezing.
Respiratory: (+) wheezing.
Cardiovascular: (-) chest pain, (-) dizziness, (+) dyspnea with exertion, (-) edema, (-) high blood pressure, (-) irregular heartbeat, (-) orthopnea, (-) palpitations, (-) paroxysmal nocturnal dyspnea, (-) Syncope.
Cardiovascular: (+) dyspnea with exertion.
Gastrointestinal: (-) abdominal pain, (-) heartburn, (-) constipation, (-) diarrhea, (-) nausea, (-) vomiting, (-) hematochezia, (-) melena, (-) change in bowel habits.

Genitourinary: (-) dysuria, (-) frequency, (-) urgency, (-) hesitancy, (-) polyuria, (-) nocturia, (-) hematuria, (-) urinary incontinence, (-) flank pain, (-) change in urinary habits.

Musculoskeletal: (-) muscle pain, (-) joint pain, (-) bone pain.

Peripheral Vascular: (-) intermittent claudication, (-) cramps, (-) varicose veins, (-) thrombophlebitis.

Neurological: (-) numbness, (-) tingling, (-) tremors, (-) seizures, (-) vertigo, (-) memory loss, (-) any focal or diffuse neurological deficits.

Endocrine: (-) heat or cold intolerance, (-) excessive sweating, (-) excessive thirst, (-) excessive hunger, (-) excessive urination, (-) hirsutism, (-) change in ring or shoe size.

Hematologic/Lymphatic: (-) anemia, (-) easy bruising, (-) excessive bleeding, (-) history of blood transfusions.

PHYSICAL EXAM:
Vitals:
BP: 143/75(Left Arm)(Standing)
Pulse: 73(Left brachial)(Standing)(Irregularly irregular)
Respiration: 12

Weight: 237 lbs
Height: 5′ 8.11″
BMI: 35.92
BSA: 2.27
BP: 178/84(Left Arm)(Supine)
Pulse: 76(Left brachial)(Supine)(Irregularly irregular)
Respiration: 12

General Appearance: The patient is an extremely pleasant 83 year old male who looks younger than his stated age. is well developed and well nourished in no apparent distress. His body habitus is obese, his mood is normal.
HEENT: Normocephalic and atraumatic. Pupils are equally round and reactive to light and accommodation. Extraocular muscles are intact. Patient’s neck is supple with no jugular venous distention, left carotid bruit was heard and carotid pulses are +2/2. Normal carotid artery upstroke bilaterally. Palpation is not painful and no thyromegaly nor lymphadenopathy can be appreciated.
Respiratory: Auscultation revealed bilateral wheezes and rhonchi. No intercostal retractions or accessory muscle use were noted.
Cardiovascular: Irregular heart rate and rhythm. Cardiac point of maximal impulse at left fifth intercostal space mid-clavicular line. Normal S1, S2 with physiologic splitting of S2. No murmurs, thrills, rubs, gallops, or clicks were heard.
Gastroenterology: Abdomen is soft non-tender and non-distended. Positive bowel sounds, no hepatomegaly or splenomegaly was noted. No bruits were heard.
Extremities: Pulses were 2+ throughout bilaterally. No clubbing. 1+ bilateral leg edema worse on the left. Bilateral tibial discoloration.
Musculoskeletal: Motor strength is appropriately intact throughout bilaterally.
Neurologic: Patient is alert and oriented x3 with deep tendon reflexes appropriately intact throughout bilaterally, non-focal.
Psychiatric: Patient is conscious, cooperative, and well-oriented to time, place, and person. There are no mood swings or psychotic features. Patient’s insight is good. Memory and judgement are intact.
Skin: No skin rash, subcutaneous nodules observed.
DIAGNOSTIC DATA:

ELECTROCARDIOGRAM: Date performed: May 24, 2016.
Indication: Worsening shortness of breath.
Interpretation: Rhythm: Afib with Vpaced and capture, VPCs.
Conclusion: Abnormal ECG.

2D COLOR DOPPLER ECHOCARDIOGRAPHY:
Date: May 24, 2016 Indication: Worsening shortness of breath, uncontrolled hypertension, Abnormal EKG.
Technically difficult study.

Findings:
Left atrium: Dimension: 4.9 cm. (Men: 3-4 cm/Women: 2.7-3.8 cm). It is moderately to severe dilated.
Left ventricle:
-LVIDd = 5.3 cm (Men:4.2-5.9 cm/Women: 3.9-5.3cm).
-LVIDs = 4.1 cm (2.0-4.1 cm).
-IVS = 1.4 cm (0.6-1.1 cm).
-LVPWd = 1.3 cm (0.6-1.1 cm).
Ventricular thickness: There is severe LV concentric hypertrophy.
Right ventricle: RVSP: 86 mmHg (15-25 mmHg). Increased right ventricular pressure.
Pulmonary Artery: There is severe pulmonary hypertension.

Aortic valve: Peak Velocity = 2.1 m/sec (1.0 – 1.7 m/sec). Mild insufficiency. Mild aortic sclerosis. moderately calcified AV leaflets.
Mitral valve: Mild regurgitation.
Tricuspid valve: Moderate regurgitation.
Pulmonic valve:
Other: IVC 2.1 cm.

Pacemaker/ICD lead: Pacemaker/ICD lead in right heart.

Recommendations:
Recommend medication adjustment. Patient declines. Also the patient declines further testing.

TREADMILL STRESS TEST/W STRESS ECHOCARDIOGRAPHY.
Date: Apr 29, 2010. Indication: Abnormal EKG
Risk and benefits of exercise stress test including but not limited to myocardial infarction, vascular compromise and death were explained to Mr. LIVSHITS in detail. The patient asked appropriate questions. All questions were answered. The patient wished to proceed and gave his informed consent. The patient completed 2 minutes 0 seconds on the Bruce Protocol achieving a heart rate of 100 beats per minutes, which represents approximately 70 % of predicted maximal heart rate. The patient did not complain of any chest pain. He did not complain of shortness of breath or dizziness. Exercise test was terminated secondary to generalized fatigue when patient achieved 70% of predicted maximal heart rate.
Electrocardiogram showed V paced with capture. Previous Stress Echocardiography with color flow Doppler and Doppler echo on 10/1/2009 reported IVS 1.6 cm, posterior wall 1.5 cm, moderate concentric LVH, left atrium 5.9 cm, ascending aorta 3.2 cm. Ejection fraction 60%. Today’s stress echocardiography showed IVS 1.3cm, posterior wall 1.3cm, Ascending Aorta 3.0cm, Left Atrium 5.4cm, Moderate concentric Left Ventricular Hypertrophy, mild Aortic Valve Sclerosis with mild Stenosis, and Pace Maker Lead in right heart. Ejection fraction 60%.
Impression: Inconclusive exercise stress/ echocardiography, predicted maximal heart rate and target exercise time duration were not achieved. EKG as detailed above. Exercise stress testing is only one diagnostic tool and is related to statistical and “pre-test probability; It may be falsely negative in the presence of significant coronary artery disease. Other diagnostic tests may be in order if new symptoms develop or if symptoms recur or change in quality or duration. The patient was instructed to contact me immediately and contact emergency medical services in this event. Given that the test was inconclusive I recommend that the patient undergo pharmacologic stress testing. Recommend an Adenosine Myocardial Perfusion Stress Rubidium PET scan. Patient agrees, and will schedule at his earliest convenience. I recommended that the patient contact emergency medical services and me if he develops any new symptoms such as chest pain or a change in their overall well being.

CAROTID ARTERY DUPLEX SCAN:
Date of Study: Oct 26, 2015.
Indication: Dizziness, Left carotid bruit.

Measurements:
Left:
CCA distal peak velocity: 109 cm/sec.
CCA end diastolic velocity: 18 cm/sec.
ICA distal peak velocity: 84 cm/sec.
ICA end diastolic velocity: 22 cm/sec.
ECA distal peak velocity: 107 cm/sec.
ECA end diastolic velocity: 16 cm/sec.
Left vertebral artery showed antegrade flow.
ICA/CCA: 0.8.
Right:
CCA distal peak velocity: 90 cm/sec.
CCA end diastolic velocity: 20 cm/sec.
ICA distal peak velocity: 58 cm/sec.
ICA end diastolic velocity: 17 cm/sec.
ECA distal peak velocity: 61 cm/sec.
ECA end diastolic velocity: 9 cm/sec.
Right vertebral artery showed antegrade flow.
ICA/CCA: 0.6.

Impression/Comments:
Left:
Left bulb plaque: less than 10%.
Left ICA: plaque less than 20%.
Left ECA: plaque less than 10%.
Right:
Right bulb plaque: less than 10%.
Right ICA: plaque less than 10%.

Plan:
Non-obstructive disease.
Will intensify medical therapy.

LOWER EXTREMITIES VENOUS DOPPLER: Feb 3, 2014.
Indication: shortness of breath, 2 to 3+ bilateral leg edema.
Impression: Normal venous flow with normal collapse with compression. Normal augmentation of venous flow with calf compression. No evidence of venous insufficiency with valsalva manuever or abdominal pressure. Normal lower extremities.
No evidence of deep venous thrombosis or venous outflow obstruction of the lower extremities by duplex scanning.

RENAL ARTERY-AORTA DUPLEX SCAN: Aug 18, 2014.
Indication: Uncontrolled hypertensive heart disease without heart failure (402.00).

Measurements:
Left Renal Peak Systolic Velocity:
Proximal: 0.34 m/s [<1.0].
Mid: 0.47 m/s [<1.0].
Distal: 0.34 m/s [<1.0].
Renal/Aortic Ratio: 0.8. [<3.5].
Right Renal Peak Systolic Velocity:
Proximal: 0.5 m/s [<1.0].
Mid: 0.51 m/s [<1.0].
Distal: 0.46 m/s [<1.0].
Renal/Aortic Ratio: 0.9. [<3.5].

Aorta:
Proximal Aortic Diameter: 1.9 cm.
Mid Aortic Diameter: 1.4 cm.
Distal Aortic Diameter: 1.2 cm.
Aortic Peak Systolic Velocity: 0.6 m/s.

Kidney:
Left:
kidney length: 11.5 cm [8.5-15.0 cm].
Kidney Width: 6.1 cm. ( 4.5-5.0 cm].
Kidney Depth (trans): 4.2 cm. [4.5-5.0].
Cortical Thickness: 1.4 cm. [1.1 cm].
Parenchymal Flow /Waveform:
Upper Early Systolic Peak Present.
Mid Early Systolic Peak Present.
Lower Early Systolic Peak Present.
Resistive Index: 0.82 [<0.75] (PSV-EDV/PSV).

Right:
kidney length: 10.8 cm [8.5-15.0 cm].
Kidney Width: 5.3 cm. ( 4.5-5.0 cm].
Kidney Depth (trans): 4.6 cm. [4.5-5.0].
Cortical Thickness: 1.4 cm. [1.1 cm].
Parenchymal Flow /Waveform:
Upper Early Systolic Peak Present.
Mid Early Systolic Peak Present.
Lower Early Systolic Peak Present.
Resistive Index: 0.76 [<0.75]
(PSV-EDV/PSV).

Technical impression: Abnormal study.
Multiple simple cysts seen in the left kidney. Most significant measures at 2.5m X 2.2cm X 2.6. No change with previous study. Follow up with Dr. Navon.

ABDOMINAL AORTA DUPLEX SCAN:
Date: Sep 16, 2013 Indication: Indication: Hypertension (401.1).

Aorta:
Proximal Aortic Diameter: 2.1 cm.
Proximal Aortic Peak Systolic Velocity: 0.84 m/s.
Mid Aortic Diameter: 1.5 cm.
Mid Aortic Peak Systolic Velocity: 0.71 m/s.
Distal Aortic Diameter: 1.3 cm.
Distal Aortic Peak Systolic Velocity: 0.45 m/s.

Technical impression:
Within normal limits.
Mild plaque seen in abdominal aorta.

PACEMAKER INTERROGATION REPORT: Date of Interrogation: Jul 5, 2016.
Implant Indication: Complete Heart Block and Chronic AF.
Implant date: 04/17/2013.
Model: MDT Versa.
Battery status: 2.79 V.
Estimated battery life: 5.5.

Atrial.
Atrial impedance: 383 Ohms.

Right Ventricular sensitivity: 2.8 mV.
Ventricular pacing: 40 %.
Mode switching episodes: Atrial high rate: 100% AF.

Final Parameters:
Mode: DDDR.
Lower rate: 70 bpm.
Atrial sensitivity: 0.35 mV.
Atrial threshold: 1.5 V at.
Right Ventricular sensitivity: 2.8 mV.
Right Ventricular threshold: 2.5 V at 0.4 ms.

Paced AV delay:
Parameter changes: None.
Statistic reset: Yes.
Underlying rhythm: Atrial Fibrillation.
Current rhythm: AF V paced 70.
Observations: Normal device function, no changes. Patient is not dependent.

Interrogation Assessment: Device function normal.
Chronic AF.

PACEMAKER INTERROGATION REPORT: Date of Interrogation: 01/05/16.
Implant date: Apr 17, 2013.
Model: Medtronic Versa DR.
Battery status: 2.79 V.
Estimated battery life: 6yr.

Right Ventricular threshold: 0.5 V at 0.4 ms.
Atrial Pacing: 0%.
Ventricular pacing: 99 %.

AHR: A-flutter.
VHR: None.

Final Parameters:
Mode: DDDR.
Lower rate: 70 bpm.
Upper rate: 130 bpm.

Atrial threshold: 1.5 V at 0. ms.
Right Ventricular threshold: 2.50 V at 0.4 ms.

Paced AV delay:150 ms.
Sensed AV delay: 120 ms.
Underlying rhythm: Atrial Fibrillation with CHB.
Current rhythm:AS/VP
Changes: None.
-Normal device function.
CT of the Abdomen: 08/30/14:
– Bilateral renal cysts.
– Fat containing peri-umbilical hernia.

CT of the Chest: CT scan of chest on 01/26/2012
1. Stable small right lower lobe nodule when compared to prior study of 06/23/2011. Likely to be benign, a follow up study in six months is recommended with thin sections obtained through this nodule to confirm stability. Small mediastinal lymph nodes are seen, with calcification in one of the paratracheal nodes.
2.The heart is mildly enlarged with dense coronary artery calcification. There is scattered aortic calcification, without aneurysm
3. A pacemaker is noted in the left chest.

Other: XRAY, NASAL BONES 08/30/14 revealed:
Suggestion of bilateral nasal fractures. CT may be considered for further characterization if indicated.

CT HEAD, NON CONTRAST. 08/30/14.
– Chronic changes of age related atrophy and small vessel ischemia disease without acute hemorrhage or infarct.
– Mild paranasal sinus disease is seen.

RENAL U/S 09/01/14:
Unremarkable renal ultrasound. Left renal cysts are noted.

Renal ultrasound on 12/17/2012. This is a limited abdominal ultrasound study of the kidneys.
Indication: H/O Renal cysts
Technique: Using real-time ultrasound and a high-resolution probe, multiple transverse and longitudinal images of both kidneys were obtained.
Findings: Bilateral kidneys appeared normal in size and echogenicity. Right kidney measures 10.4 cm x 4.4 cm x 4.7 cm. Left kidney measures 11.5 cm x 5.0 cm x 4.4 cm. No definite solid masses or hydronephrosis are identified. No free fluid is seen.
Impression: The study shows (2) simple cysts seen in the left kidney measuring 2.2cm x 2.1cm x 1.9cm and 1.5cm x 1.4cm x 1.4cm. No change compared with prior study.
Plan: Recommends follow up with Dr. Navon

Adenosine Myocardial Perfusion Stress Rubidium PET Scan performed on 5/5/2010, reason shortness of breath, reported clinical response -nonischemic, EKG response – non diagnostic, perfusion -normal, function- normal. Likelihood of jeopardized myocardium: low (< 10%). The right ventricle is prominent suggesting right ventricular hypertrophy. Incidental findings from CT scan: extensive coronary atherosclerosis, extensive calcification of aorta, 6 mm noncalcified nodule in the right lower lobe. Recommend CT chest in 3-6 months for further evaluation.

EP study performed on 12/03/2008 showed typical counterclockwise tricuspid valve dependent flutter, 2 morphologies. Successful ablation of flutter, terminating flutter and creating bidirectional isthmus conduction block with and without isoproterenol, sick sinus syndrome, normal pacemaker function.
.

Colonoscopy: Patient advised 3/2/15 to get screening colonoscopy but absolutely declined.
PSA level: 0.4 ng/ml on 01/07/14.
FLU VACCINATION: 2014, declines.

————————————————————————————————————————————————————
DIAGNOSIS/ASSESSMENT:

HIGH RISK PATIENT. HE NEEDS CLOSE FOLLOW UP TO AVOID RECURRENT HOSPITALIZATION.

EXACERBATION OF HEART FAILURE
WORSENING SHORTNESS OF BREATH/LEG EDEMA/ COUGH
Moderate. Bumex 2 mg PO STAT was given in the office. Labs were performed. The patient instructed to go diredtly to ER Providence Tarzana Hospital. EKG showed atrial fibrillation, Vpaced and capture. Severe LV concentric hypertrophy, severe pulmonary hypertension, left atrium moderately to severely dilated, mild aortic valve insufficiency, mild aortic sclerosis, moderate calcified AV leaflets, moderate tricuspid regurgitation, mild mitral valve regurgitation and pacemaker/ICD in right ventricle per echocardiography. Low likelihood of jeopardized myocardium per PET scan on 05/05/10. I had a long discussion with the patient regarding diagnostic and therapeutic options, including cardiac catheterization to rule out coronary artery disease. The patient wishes to consider his options for now. Continue Lasix, hold if sBP is less than 110 mmHg. Will follow him carefully with frequent labs. The patient was advised of the importance of following a healthy low salt diet, weight loss and daily aerobic exercise. He was instructed to contact me if his symptom worsens, or he develops new symptoms.

COMPLEX PATIENT WITH MULTIPLE MEDICAL PROBLEMS.
Patient is currently in atrial fibrillation. A long discussion was held with the patient and his wife in regards to therapeutic options, including but not limited to repeat cardiac catheterization to assess coronary arteries or radiofrequency ablation/BiV pacing, and continued medical therapy. The benefits, risks, and alternatives were discussed at great length. The patient wishes to consider his options for now. He was informed that Pradaxa may be contributing to his renal insufficiency. The patient absolutely declines Coumadin therapy and wishes to continue Pradaxa. The patient and his wife were informed of the risks of doing so. Will continue to optimize patient’s medical therapy for now and follow his symptoms closely. Patient was instructed to call immediately if his condition worsens. Follow up with his internist is recommended.

LEG EDEMA.
Patient to raise his lower extremities above heart level for 30 minutes, 3-4 times daily and follow a low salt diet. Continue Lasix prn.

H/O DIZZINESS/SYNCOPE- no recurrence
S/P FALL.
-Left carotid bruit.
No orthostatic changes on physical examination today. Non-obstructive disease as outlined above. Brain CT scan on 08/30/14 revealed no acute changes. XR nasal bones showed evidence of bilateral fractures. The patient has not had a recurrence of his symptoms off Zaroxolyn. He was advised to rise slowly from a supine/seated position, and remain well hydrated at all times. He is to lay down and raise his lower extremities if his symptoms recur. He was also advised to contact me or emergency services immediately if he has a recurrence of symptoms. He has been provided with my cell phone number.

ELECTROLYTE IMBALANCE.
H/O HYPOKALEMIA/HYPONATREMIA/ACUTE RENAL FAILURE.
Likely medication related. Potassium 4.9 mmol/L, Sodium 140 mmol/L, BUN 24 mg/dl, Creatinine 0.95 mg/dl per labs on 09/20/15. Serial labs advised.

HYPERTENSIVE HEART DISEASE WITHOUT CHF.
Moderate concentric left ventricular hypertrophy per echocardiography. Renal artery duplex showed no evidence of renal artery stenosis. Continue current medications. A salt restricted diet is advised. Optimal blood pressure, with target sBP of 110-120mmHg advised.
CARDIAC PACEMAKER IN SITU.
Status post pacemaker pulse generator replacement. Normal device function.

PERSISTENT ATRIAL FIBRILLATION/ATRIAL FLUTTER/ DILATED LEFT ATRIUM.
He is on Pradaxa therapy. He declines Coumadin therapy. The patient was advised to avoid alcohol, caffeine, and other stimulants, which may precipitate his condition. Will continue to follow him closely.

NON SUSTAINED VENTRICULAR TACHYCARDIA.
No recurrence per device interrogation 07/20/15.

DYSLIPIDEMIA.
LDL 125 mg/dl and HDL 89 mg/dl per labs on 09/20/15. The patient is off Crestor given abnormal renal function. Lipitor was discontinued by the patient’s internist. Defer to his internist.

GENERALIZED ATHEROSCLEROSIS.
CT scan performed on 05/05/10 revealed extensive coronary atherosclerosis and extensive calcification of aorta. Follow-up CT scan of the chest on 10/26/10 revealed scattered aortic calcification without aneurysm. Abdominal aortic ultrasound revealed mild plaque. Carotid artery duplex scan performed on 03/31/11 revealed right bulb plaque along the posterior wall and an echogenic homogeneous round structure consistent with plaque <40%. Recommend aggressive lifestyle modification including a healthy diet, weight loss, and a daily aerobic exercise program.

OTHER:
1. Incidental finding of lung nodule on CT scan: 6 mm non-calcified nodule in the right lower lobe. CT of the chest on 1/26/12 revealed no changes compared with the previous study. Lung nodule has remained stable. No further follow up advised per radiology.
2. Hyperuricemia/History of gouty arthritis. Uric acid 6.1 mg/dl on 05/19/14. The patient is on Allopurinol. A low purine diet is advised. Defer management to his internist.
3. Memory impairment. Defer to the patient’s internist.
4. Chronic back pain/leg pain/knee pain. Defer to his internist.
5. Anemia. Defer to his internist.
6. GAIT DISTURBANCE. The patient walks with the assistance of a cane.

DISCUSSION:

PLAN:
EMERGENCY ROOM: The patient was instructed to proceed directly to the nearest hospital for further evaluation and management. Patient declined EMS services. Patient will transport themselves to the hospital now.
.

Medication changes: Bumex 2 mg PO STAT in office today.

Laboratory: Chem 24, BNP.

Procedures performed today: EKG, Complete Echocardiogram.

——————————————————————————————————————————————————-

Check in time: 07:37 AM Check out time: 09:12 AM

Electronically signed: 07/06/2016 10:17 AM BENZUR, URI

99215 Office/outpatient visit, est, high; G8427 Med.with dosage and verification documented; 1036F CURRENT TOBACCO NON-USER CAD CAP COPD PV DM; 93288 Pacer Check Dual; G8419 BMI abnormal. No followup plan documented

Uri M. Ben-Zur, M.D., F.A.C.C.
Interventional Cardiology / Invasive Electrophysiology

18200 Ventura Blvd
Tarzana, CA 91356
Phone (818) 986-0911 Fax (818) 986-9301
Date of visit: 07/05/2016
Reason for Visit:
Requesting Physician:
I had the opportunity to evaluate on the date stated above. I have reviewed the past medical history, symptoms and current therapy. In addition, I have examined the patient and based on my findings have provided my overall impression, outlining my treatment and plans in the summary below.

CHIEF COMPLAINT /HISTORY OF PRESENT ILLNESS:

Ms. INNA LIVSHITS is an extremely pleasant 82 year old female with a past medical history of hypertension, dyslipidemia, and diabetes mellitus. She is accompanied today by her husband, Anri.

The patient complains of occasional shortness of breath with mild to moderate exertion. This symptom has existed for an extended period of time and has been stable. It is mild in severity. No associated symptoms noted.

The patient complains of occasional bilateral leg swelling. It is mild to moderate in severity. It is noticeable at the end of the day and resolves by the following morning. No associated symptoms noted.

The patient is on Iron and Vitamin B12 supplementation per her internist’s recommendation.

The patient denies chest pain, palpitations, dizziness, syncope.

She does not monitor her blood pressure at home. She does not monitor her blood sugar at home. The patient does not follow an exercise program. She does not follow a specific diet.

At the time of her last visit, no medication changes were made.

Overall, states that she is stable.
PAST MEDICAL HISTORY:
Cardiovascular:
Hyperlipidemia.
Hypertension, benign essential.
Musculoskeletal:
Osteoarthritis.
Osteoporosis.
Endocrine:
Diabetes mellitus.
SURGICAL HISTORY:
Hysterectomy (2011).

CURRENT MEDICATIONS:
1 Allopurinol 100 Mg Tablet SIG: PRN
2 Amlodipine Besylate 5 Mg Tab SIG: Take 1 tab by mouth once daily
3 Aspirin Ec 81 Mg Tab SIG: Take 1 tab by mouth once daily
4 Benicar Hct 40-25 Mg Tablet SIG: Take 1 tab by mouth once daily
5 Clonidine Hcl 0.1 Mg Tablet SIG: PRN if systolic BP> 150 mm Hg
6 Furosemide 20 Mg Tablet SIG: one tablet PO twice a week
7 Lipitor 80 Mg Tablet SIG: Take 1 tab by mouth once daily
8 Namenda 10 Mg Tablet SIG: Take 1 tab by mouth once daily
9 Nexium Dr 40 Mg Capsule SIG: Take 1 cap by mouth once daily
10 Toprol Xl 100 Mg Tablet SIG: Take 1 tab by mouth once daily
11 B12 2,500 Mcg Tablet Sl SIG: 1Tab PO QD
12 Iron 325 Mg Tablet (65 Mg Iron) SIG: 1 Tab po qd
13 Metformin Hcl 500 Mg Tablet (Other MD) SIG: one tab PO Q AM and 850 mg PO QPM

ALLERGIES / INTOLERANCES:
No Known Drug Allergy

SOCIAL HISTORY:
Marital Status: The patient is married.
Smoking/tobacco use: No history of smoking.
Alcohol: Non alcoholic beverage drinker.
Recreational drug use: She denies recreational drug use.
Diet: No diet restrictions.
Caffeine Intake: Drinks coffee 1 cup(s) a day.

FAMILY HISTORY:
Father is deceased. He died at the age of 72 due to myocardial infarction.
Mother is deceased. She died at the age of 64 due to CVA. H/o DM, HTN.
2 sisters. Her first sister is 78 years old. She has diabetes type 2, dyslipidemia and hypertension. Her second sister is 67 years old. She has diabetes type 2, dyslipidemia and hypertension.
REVIEW OF SYSTEMS:
Constitutional Symptoms: (-) fever, (-) chills, (-) night sweats, (-) fatigue, (-) weakness, (-) changes in appetite or weight.

Integumentary: (-) rash, (-) lumps, (-) itching, (-) dryness, (-) acne, (-) discoloration, (-) recurrent skin infections, (-) changes in hair, nails or moles.

Respiratory: (-) cough, (-) hemoptysis, (-) cyanosis, (-) wheezing, (-) nocturnal choking or gasping.

Cardiovascular: (-) chest pain, (-) dizziness, (+) dyspnea with exertion, (+) edema, (+) high blood pressure, (-) irregular heartbeat, (-) orthopnea, (-) palpitations, (-) Syncope.
Cardiovascular: (+) dyspnea with exertion, (+) edema, (+) high blood pressure.
Gastrointestinal: (-) abdominal pain, (-) heartburn, (-) constipation, (-) diarrhea, (-) nausea, (-) vomiting, (-) hematochezia, (-) melena, (-) change in bowel habits.

Genitourinary: (-) dysuria, (-) frequency, (-) urgency, (-) hesitancy, (-) polyuria, (-) nocturia, (-) hematuria, (-) urinary incontinence, (-) flank pain, (-) change in urinary habits.

Musculoskeletal: (-) muscle pain, (-) joint pain, (-) bone pain.

Peripheral Vascular: (-) intermittent claudication, (-) cramps, (-) varicose veins, (-) thrombophlebitis.

Neurological: (-) numbness, (-) tingling, (-) tremors, (-) seizures, (-) vertigo, (-) memory loss, (-) any focal or diffuse neurological deficits.

Endocrine: (-) heat or cold intolerance, (-) excessive sweating, (-) excessive thirst, (-) excessive hunger, (-) excessive urination, (-) hirsutism, (-) change in ring or shoe size.

Hematologic/Lymphatic: (-) anemia, (-) easy bruising, (-) excessive bleeding, (-) history of blood transfusions.

PHYSICAL EXAM:
Vitals:
Weight: 150 lbs
BP: 202/95(Left Arm)(Standing)
Pulse: 66(Left brachial)(Standing)

Weight: 153 lbs
Height: 152 Cms
BMI: 30.04
BSA: 1.71
BP: 192/105(Left Arm)(Supine)
Pulse: 68(Left brachial)(Supine)

General Appearance: The patient is an extremely pleasant 82 year old female who looks younger than her stated age. is well developed and well nourished in no apparent distress. Her body habitus is within normal limits. Her mood is normal.
HEENT: Normocephalic and atraumatic. Pupils are equally round and reactive to light and accommodation. Extraocular muscles are intact. Patient’s neck is supple with no jugular venous distention, no carotid bruit was heard and carotid pulses are +2/2. Normal carotid artery upstroke bilaterally. Palpation is not painful and no thyromegaly nor lymphadenopathy can be appreciated.
Respiratory: Clear to auscultation bilaterally without wheezes or rhonchi. No intercostal retractions or accessory muscle use were noted.
Cardiovascular: Regular heart rate and rhythm. Cardiac point of maximal impulse at left fifth intercostal space mid-clavicular line. Normal S1, S2 with physiologic splitting of S2. No murmurs, thrills, rubs, gallops, or clicks were heard.
Gastroenterology: Abdomen is soft non-tender and non-distended. Positive bowel sounds, no hepatomegaly or splenomegaly was noted. No bruits were heard.
Extremities: Pulses were 2+ throughout bilaterally. No cyanosis, edema or clubbing.
Musculoskeletal: Motor strength is appropriately intact throughout bilaterally.
Neurologic: Patient is alert and oriented x3 with deep tendon reflexes appropriately intact throughout bilaterally, non-focal.
Psychiatric: Patient is conscious, cooperative, and well-oriented to time, place, and person. There are no mood swings or psychotic features. Patient’s insight is good. Memory and judgement are intact.
Skin: No skin rash, subcutaneous nodules, lesions or ulcers observed.
DIAGNOSTIC DATA:

ELECTROCARDIOGRAM: Date performed: Jul 5, 2016.
Indication: Occasional shortness of breath and worsening leg edema.
Interpretation: Rate: 61 bpm; Rhythm: Normal sinus rhythm and 1st degree AV Block PR=0.22ms; Left Ventricular Hypertrophy.
Conclusion: Abnormal ECG.

2D COLOR DOPPLER ECHOCARDIOGRAPHY:
Date: Jul 5, 2016 Indication: Worsening shortness of breath, increasing leg edema, Abnormal EKG.
Technically difficult study.

Findings:
Left atrium: Dimension: 4.1 cm. (Men: 3-4 cm/Women: 2.7-3.8 cm).
Left ventricle:
-LVIDd = 3.6 cm (Men:4.2-5.9 cm/Women: 3.9-5.3cm).
-LVIDs = 1.8 cm (2.0-4.1 cm).
-IVS = 1.4 cm (0.6-1.1 cm).
-LVPWd = 1.1 cm (0.6-1.1 cm).
Ventricular thickness: There is moderate LV concentric hypertrophy.
Wall kinesis: There is E-A flow reversal suggestive of diastolic dysfunction.

Right atrium: Normal in size and shape and shows no signs of ASD, mass or thrombus.
Right ventricle: Normal in size and shape and shows no signs of VSD, mass or thrombus.

Aortic valve: Normal trileaflet aortic valve.
Mitral valve: Mild regurgitation. No sclerosis. No stenosis. No valve prolapse. Mild annular calcification is noted.
Tricuspid valve: Mild regurgitation. No sclerosis. No stenosis.
Pulmonic valve: Normal pulmonic valve.
Aorta: Ascending aorta: 3.2 cm. ( 2.1-3.4 cm), No evidence of aortic aneurysm.

Left ventricle ejection fraction: 60 %.

Pericardium: No effusion or calcification.
Venous: Inferior vena cava: Normal diameter with normal respiratory variation.

CAROTID ARTERY DUPLEX SCAN:
Date of Study: Oct 27, 2014.
Indication: Left carotid bruit.

Measurements:
Left:
CCA distal peak velocity: 75 cm/sec.
CCA end diastolic velocity: 20 cm/sec.
ICA distal peak velocity: 153 cm/sec.
ICA end diastolic velocity: 51 cm/sec.
ECA distal peak velocity: 99 cm/sec.
ECA end diastolic velocity: 16 cm/sec.
Left vertebral artery showed antegrade flow.
ICA/CCA: 2.
Right:
CCA distal peak velocity: 61 cm/sec.
CCA end diastolic velocity: 18 cm/sec.
ICA distal peak velocity: 89 cm/sec.
ICA end diastolic velocity: 34 cm/sec.
ECA distal peak velocity: 116 cm/sec.
ECA end diastolic velocity: 14 cm/sec.
Right vertebral artery showed antegrade flow.
ICA/CCA: 1.5.

Impression/Comments:
Left:
Left bulb plaque: less than 20%.
Left CCA: plaque 20%.
Right:
Right bulb calcified plaque: less than 30%.

Plan:
Non-obstructive disease.
Will intensify medical therapy.

RENAL ARTERY-AORTA DUPLEX SCAN: Feb 9, 2016.
Indication: Uncontrolled hypertensive heart disease without heart failure (402.00).

Measurements:
Left Renal Peak Systolic Velocity:
Proximal: 0.76 m/s [<1.0].
Mid: 0.42 m/s [<1.0].
Distal: 0.82 m/s [<1.0].
Renal/Aortic Ratio: 1.5. [<3.5].
Right Renal Peak Systolic Velocity:
Proximal: 0.61 m/s [<1.0].
Mid: 0.47 m/s [<1.0].
Distal: 0.41 m/s [<1.0].
Renal/Aortic Ratio: 1.1. [<3.5].

Aorta:
Proximal Aortic Diameter: 1.8 cm.
Mid Aortic Diameter: 1.6 cm.
Distal Aortic Diameter: 1.2 cm.
Aortic Peak Systolic Velocity: 0.55 m/s.

Kidney:
Left:
kidney length: 10 cm [8.5-15.0 cm].
Kidney Width: 4 cm. ( 4.5-5.0 cm].
Kidney Depth (trans): 4.7 cm. [4.5-5.0].
Cortical Thickness: 1 cm. [1.1 cm].
Parenchymal Flow /Waveform:
Upper Early Systolic Peak Present.
Mid Early Systolic Peak Present.
Lower Early Systolic Peak Present.
Resistive Index: 0.66 [<0.75] (PSV-EDV/PSV).

Right:
kidney length: 9.4 cm [8.5-15.0 cm].
Kidney Width: 3.8 cm. ( 4.5-5.0 cm].
Kidney Depth (trans): 4 cm. [4.5-5.0].
Cortical Thickness: 1.2 cm. [1.1 cm].
Parenchymal Flow /Waveform:
Upper Early Systolic Peak Present.
Mid Early Systolic Peak Present.
Lower Early Systolic Peak Present.
Resistive Index: 0.8 [<0.75]
(PSV-EDV/PSV).

Findings: Evidence of multiple small renal calculi seen in the left kidney. Patient wishes to defer medication changes to her primary care doctor. Follow up with Dr. Navon.

Technical impression: Abnormal study..

ABDOMINAL AORTA DUPLEX SCAN:
Date: Nov 17, 2014 Indication: Indication: Hypertension (401.1) Atherosclerosis of the Aorta (440.0).

Aorta:
Proximal Aortic Diameter: 2.1 cm.
Proximal Aortic Peak Systolic Velocity: 0.6 m/s.
Mid Aortic Diameter: 1.7 cm.
Mid Aortic Peak Systolic Velocity: 0.58 m/s.
Distal Aortic Diameter: 1.1 cm.
Distal Aortic Peak Systolic Velocity: 0.6 m/s.

Technical impression:
Within normal limits.
Mild plaque seen in abdominal aorta.

Colonoscopy: No colonoscopy has ever been performed. I offered to do colonoscopy on several occasions. The patient absolutely declines.
Endoscopy: DECLINES.
Dexa scan: No DEXA scan has ever been performed.
Mammogram: No mammogram has ever been performed.
Pap Test: No pap smear exam has ever been performed.
FLU VACCINATION: 2014, declines.
PNEUMOVAX: DECLINES.

————————————————————————————————————————————————————
DIAGNOSIS/ASSESSMENT:

DYSPNEA.
Mild. Stable. Multifactorial. Patient with a relatively sedentary lifestyle and multiple risk factors for coronary artery disease. Today’s EKG revealed normal sinus rhythm, 1st degree AV block, and LVH. Echocardiography revealed mild tricuspid valve regurgitation, mild mitral valve regurgitation, mild diastolic dysfunction, EF 60%. Recommend exercise stress test or myocardial perfusion scanning to assess her coronary arteries. The patient was advised of the importance of cardiac risk factor modification, including optimal blood pressure, blood sugar, lipid profile, a healthy diet, weight loss and daily aerobic exercise. She is to contact me or emergency services if this symptom worsens, or she develops new symptoms.

LEG EDEMA.
Recommend that the patient raise her lower extremities above heart level for 30 minutes, 3-4 times daily and follow a low salt diet.

HYPERTENSION, ESSENTIAL.
Difficult to control. Moderate left ventricular hypertrophy per echocardiography. No evidence of renal artery stenosis or abdominal aortic aneurysm per Duplex scanning. Recommend that the patient monitor her blood pressure twice daily and provide me with the records. Target systolic blood pressure in the 110-120 mmHg range recommended. Low salt, healthy diet advised. Will defer medication adjustments to the patient’s internist, per her request.

DYSLIPIDEMIA.
LDL 111 mg/dL, HDL 56 mg/dL on 05/09/16. Continue Lipitor. Low fat, healthy diet and daily aerobic exercise advised.

DIABETES MELLITUS TYPE II.
HbA1c 6.6% per labs on 05/09/16. The patient is on Metformin. Low carbohydrate, healthy diet advised. Defer management to the patient’s internist.

OTHER:
– Evidence of multiple small renal calculi seen in the left kidney per renal duplex. Follow up with Dr. Navon advised.
– Anemia. Defer management to her internist.

DISCUSSION:

PLAN:
Medication changes: No.

Procedures performed today: EKG, Complete Echocardiogram.

Diet: Patient advised to follow a healthy low fat, salt and carbohydrate diet.

Exercise recommendations: Regular exercise is strongly recommended.

Hypertension Instructions: The patient was instructed to monitor their blood pressure twice daily and provide me with the records.

Leg edema recommendations: The patient was advised to raise their legs over heart level for 30 minutes 3 times a day.

Follow Up: The patient was advised to return to the office for follow up in 1 month or earlier if she has any medical problems.

Emergency recommendations: The patient was advised to call 911 or go to the emergency room if the patient’s condition worsens or does not improve.

——————————————————————————————————————————————————-

Check in time: 07:37 AM Check out time: 09:12 AM

Electronically signed: 07/06/2016 09:46 AM BENZUR, URI

99214 Office/outpatient visit, est, mod; G8427 Med.with dosage and verification documented; 1036F CURRENT TOBACCO NON-USER CAD CAP COPD PV DM; 93000 Electrocardiogram, complete (ECG); 93306 echo 2Dw/doppler echo/color flow doppler; G8419 BMI abnormal. No followup plan documented

Uri M. Ben-Zur, M.D., F.A.C.C.
Interventional Cardiology / Invasive Electrophysiology

18200 Ventura Blvd
Tarzana, CA 91356
Phone (818) 986-0911 Fax (818) 986-9301
Date of visit: 07/05/2016
Reason for Visit:
Requesting Physician:
I had the opportunity to evaluate on the date stated above. I have reviewed the past medical history, symptoms and current therapy. In addition, I have examined the patient and based on my findings have provided my overall impression, outlining my treatment and plans in the summary below.

CHIEF COMPLAINT /HISTORY OF PRESENT ILLNESS:

Mis an extremely pleasant 53 year old male with a past medical history of premature ventricular contractions, hypertension and dyslipidemia. His family history is significant for coronary artery disease.

The patient complains of occasional palpitations, described as fast heartbeats. He reports an episode on 06/29/16, which lasted 2 hours, and another yesterday, which lasted a few seconds. No associated symptoms noted.

The patient states that he restarted taking Lexapro 3 days ago.

The patient denies any recent episodes of chest pain, shortness of breath, dizziness, or syncope.

His blood pressure readings have been within normal limits at home. Mr. HASSON is following an exercise program. He walks for 60 minutes, 7 days a week. He follows a healthy diet.

Overall, states that he is stable.
PAST MEDICAL HISTORY:
Cardiovascular:
Hypertension, benign essential.
Premature ventricular contractions.
Endocrine:
Hyperlipidemia.

CURRENT MEDICATIONS:
1 Fish Oil 1,000 Mg Softgel 1,000 (120-180) SIG: TID
2 Cholest Off 450 Mg Caplet SIG: Take 1 daily
3 Hdl Booster SIG: Take 1 daily
4 Red Yeast Rice 300 Mg Capsule SIG: Take 2 daily
5 Aspirin 81 Mg Tablet SIG: one daily
6 Lexapro 10 Mg Tablet SIG: 1 tab PO QD

ALLERGIES / INTOLERANCES:
No Known Drug Allergy

SOCIAL HISTORY:
Stress level: high
Marital status: married, with 3 children
Caffeine use: He consumes 1-2 cups per day
No Tobacco use
No Illegal drug use
No Alcohol use.

FAMILY HISTORY:
Father alive. History of premature coronary artery disease. S/p myocardial infarction x3 (1st in his late 40s), s/p stent placement 2005. History of hyperlipidemia and tobacco use. He was a heavy smoker, 3-4 packs/day.
Mother alive. History of Non-Hodgkin’s lymphoma.
REVIEW OF SYSTEMS:
Constitutional Symptoms: (-) fever, (-) chills, (-) night sweats, (-) fatigue, (-) weakness, (-) changes in appetite or weight.

Integumentary: (-) rash, (-) lumps, (-) itching, (-) dryness, (-) acne, (-) discoloration, (-) recurrent skin infections, (-) changes in hair, nails or moles.

Ears, Nose, Mouth, Throat: (-) hearing changes, (-) tinnitus, (-) vertigo, (-) dizziness, (-) earache, (-) ear infection, (-) ear discharge, (-) use of hearing aids. Neck: (-) swollen glands, (-) enlarged thyroid, (-) neck pain.

Respiratory: (-) cough, (-) hemoptysis, (-) cyanosis, (-) wheezing, (-) nocturnal choking or gasping.

Cardiovascular: (-) chest pain, (-) dizziness, (-) dyspnea with exertion, (-) edema, (-) high blood pressure, (-) irregular heartbeat, (-) orthopnea, (+) palpitations, (-) paroxysmal nocturnal dyspnea, (-) shortness of breath.
Cardiovascular: (+) palpitations.
Gastrointestinal: (-) abdominal pain, (-) heartburn, (-) constipation, (-) diarrhea, (-) nausea, (-) vomiting, (-) hematochezia, (-) melena, (-) change in bowel habits.

Genitourinary: (-) dysuria, (-) frequency, (-) urgency, (-) hesitancy, (-) polyuria, (-) nocturia, (-) hematuria, (-) urinary incontinence, (-) flank pain, (-) change in urinary habits.

Musculoskeletal: (-) muscle pain, (-) joint pain, (-) bone pain.

Peripheral Vascular: (-) intermittent claudication, (-) cramps, (-) varicose veins, (-) thrombophlebitis.

Neurological: (-) numbness, (-) tingling, (-) tremors, (-) seizures, (-) vertigo, (-) memory loss, (-) any focal or diffuse neurological deficits.

Endocrine: (-) heat or cold intolerance, (-) excessive sweating, (-) excessive thirst, (-) excessive hunger, (-) excessive urination, (-) hirsutism, (-) change in ring or shoe size.

Hematologic/Lymphatic: (-) anemia, (-) easy bruising, (-) excessive bleeding, (-) history of blood transfusions.

PHYSICAL EXAM:
Vitals:
BP: 125/86(Left Arm)(Standing)
Pulse: 82(Left brachial)(Standing)(Regular)
Respiration: 12

Weight: 163 lbs
Height: 5′ 10”
BMI: 23.39
BSA: 1.91
BP: 124/76(Left Arm)(Supine)
Pulse: 74(Left brachial)(Supine)(Regular)
Respiration: 12

General Appearance: The patient is an extremely pleasant 53 year old male who looks younger than his stated age. is well developed and well nourished in no apparent distress. His body habitus is within normal limits. His mood is normal.
HEENT: Normocephalic and atraumatic. Pupils are equally round and reactive to light and accommodation. Extraocular muscles are intact. Patient’s neck is supple with no jugular venous distention, no carotid bruit was heard and carotid pulses are +2/2. Normal carotid artery upstroke bilaterally. Palpation is not painful and no thyromegaly nor lymphadenopathy can be appreciated.
Respiratory: Clear to auscultation bilaterally without wheezes or rhonchi. No intercostal retractions or accessory muscle use were noted.
Cardiovascular: Regular heart rate and rhythm. Cardiac point of maximal impulse at left fifth intercostal space mid-clavicular line. Normal S1, S2 with physiologic splitting of S2. No murmurs, thrills, rubs, gallops, or clicks were heard.
Gastroenterology: Abdomen is soft non-tender and non-distended. Positive bowel sounds, no hepatomegaly or splenomegaly was noted. No bruits were heard.
Extremities: Pulses were 2+ throughout bilaterally. No cyanosis, edema or clubbing.
Musculoskeletal: Motor strength is appropriately intact throughout bilaterally.
Neurologic: Patient is alert and oriented x3 with deep tendon reflexes appropriately intact throughout bilaterally, non-focal.
Psychiatric: Patient is conscious, cooperative, and well-oriented to time, place, and person. There are no mood swings or psychotic features. Patient’s insight is good. Memory and judgement are intact.
Skin: No skin rash, subcutaneous nodules, lesions or ulcers observed.
DIAGNOSTIC DATA:

ELECTROCARDIOGRAM: Date performed: Mar 20, 2012.
Indication: “Tense chest”.
Interpretation: Rate: 94 bpm; Rhythm: Normal sinus rhythm.
Conclusion: Normal ECG.

2D COLOR DOPPLER ECHOCARDIOGRAPHY:
Date: Mar 20, 2012 Indication: Atypical chest pain.

Right atrium: Normal in size and shape and shows no signs of ASD, mass or thrombus.
Right ventricle: RVSP: 26 mmHg (15-25 mmHg). Normal right ventricular pressure. Normal in size and shape and shows no evidence of VSD or mass.

Aortic valve: Normal trileaflet aortic valve.
Mitral valve: Normal mitral valve without prolapse.
Tricuspid valve: Mild regurgitation. No sclerosis. No stenosis.
Pulmonic valve: Normal pulmonic valve.
Aorta: No evidence of dissection, coarctation or aneurysm of the aorta.

Left ventricle ejection fraction: 65 %.

Pericardium: No effusion or calcification.
Venous: Inferior vena cava: Normal diameter with normal respiratory variation.

TREADMILL STRESS TEST/W STRESS ECHOCARDIOGRAPHY.
Date: May 7, 2013. Indication: Patient requested
Risk and benefits of exercise stress test including but not limited to myocardial infarction, vascular compromise and death were explained to Mr. HASSON in detail. The patient asked appropriate questions. All questions were answered. The patient wished to proceed and gave his informed consent.

Protocol: Standard Bruce protocol.

Procedure:
STAGE I (Min 0 to 2:50): Min: 2 . MPH: 1.7. Grade: 10 %. MET: 1-5. BP: 155/75, Pulse: 126, O2 Sat: 99.
STAGE II (Min 3 to 5:50): Min: 5 . MPH: 2.5. Grade: 12%. MET: 6-7. BP: 160/80, Pulse: 140, O2 Sat: 99.
STAGE IV (Min 9 to 11:50): Min: 9 . MPH: 4.2. Grade 16%. MET: 10-12. BP: 160/80, Pulse: 148, O2 Sat: 97.
STAGE V (Min 12 to 14:50): Min: 12 . MPH: 5. Grade 18%. MET 14-16. BP: 180/90, Pulse: 163, O2 Sat: 98.

Results:
Maximal Predicted Heart Rate: 170 bpm.
Peak heart rate achieved: 174 bpm.
Maximal heart rate achieved: 100 % of predicted heart rate.
Average O2 saturation throughout the study: 98 %.
Total Minutes: 15.12.
Reason for stopping: Target heart rate achieved.

Clinical response:
Peak exercise electrocardiogram demonstrated no significant ischemic changes nor arrhythmias.

Stress echocardiography:
Revealed normal left ventricular function at rest with an adequate increase in left ventricular function in response to exercise.

Summary: The patient exercised according to the BRUCE protocol for a total of 15.12 minutes, achieving a peak heart rate of 174 bpm, 100% of the maximum predicted heart rate. Electrocardiogram showed no significant ST-T changes. Atrial premature contractions/ventricular premature contractions/dysrhythmias were not seen.
Blood pressure response to exercise was normal at 180/90 mmHg.
Symptoms at peak exercise: The patient had no symptoms and tolerated the exercise well.
The study revealed an adequate cardiovascular exercise stress test with a normal hemodynamic response to exercise.

Conclusion:
Response to exercise: The exercise test revealed a good hemodynamic response to exercise.
There is no evidence of inducible ischemia at the level of exercise achieved.
No evidence of stress induced arrhythmias at the level of exercise achieved.
The patient had an adequate exercise capacity.
Probability of obstructive coronary artery disease: Low. It was discussed with the patient that coronary artery disease may be present despite the results of the exercise stress test. Exercise stress testing is only one diagnostic tool and is related to statistical and “pre-test probability”. It may be falsely negative in the presence of significant coronary artery disease. Other diagnostic tests may be in order if new symptoms develop or if symptoms recur or change in quality or duration. The patient was instructed to contact me immediately and contact emergency medical services in this event.
Other: Treadmill stress test with echocardiographic imaging 5/7/2010 (4v): Indication: Positive risk factors for CAD. Exercise stress testing was performed for the evaluation of coronary ischemia and to assess exercise tolerance.
The patient was told the risk and benefits of exercise stress test including but not limited to myocardial infarction, vascular compromise and death. The patient asked appropriate questions. All questions were answered and the patient wished to proceed and gave his informed consent. The patient completed 15 minutes 19 seconds on the Bruce Protocol achieving a heart rate of 151 beats per minutes, which represents approximately 87% of predicted maximal heart rate. The patient did not complain of any chest pain. He did not complain of shortness of breath or dizziness. Exercise test was terminated secondary to generalized fatigue when patient achieved 87% of predicted maximal heart rate.
Electrocardiogram showed 1/2 mm ST depression in leads V4, V5 and V6. Atrial premature contractions/ ventricular premature contractions / dysrhythmias were not seen. Normal left ventricular function pre and post exercise. The oxygen saturation was more than 95% throughout exercise test.
Previous Stress Echocardiography with color flow Doppler and Doppler echo on 5/27/2009 reported normal left ventricular function. Ejection fraction 65%. Today’s stress echocardiography reveals normal left ventricular function at rest with an adequate increase in left ventricular function in response to exercise. Stress echocardiography showed normal right heart size and function, normal mitral valve, no prolapse, normal trileaflet aortic valve, and negative pericardial effusion, no thrombus, no vegetations. Ejection fraction 65%.
Impression: Assessment of exercise test revealed good hemodynamic response to exercise, predicted maximal heart rate was achieved. Adequate oxygen saturation. EKG changes as detailed above without inducible ischemia or evidence of obstructive coronary artery disease. The patient has no inducible coronary ischemia at the level of exercise achieved based on the exercise stress / echocardiography test performed today. It was discussed with the patient that coronary artery disease may be present notwithstanding the results of the exercise stress test. Exercise stress testing is only one diagnostic tool and is related to statistical and “pre-test probability; It may be falsely negative in the presence of significant coronary artery disease. Other diagnostic tests may be in order if new symptoms develop or if symptoms recur or change in quality or duration. The patient was instructed to contact me immediately and contact emergency medical services in this event. I recommended that the patient contact emergency medical services and me if he develops any new symptoms such as chest pain or a change in their overall well being. The patient’s valvular dysfunction has remained stable.

Holter monitoring 11/11/2008, indication: palpitations, shows normal sinus rhythm, occasional APCs and occasional VPCs.

Carotid artery duplex scan Date: 4/27/2010. Indication: Dizziness.
RIGHT
Right External Carotid Artery Velocity: 97 cm/s
Right Distal Internal Carotid Artery Velocity: 73 cm/s
Right Distal Common Carotid Artery Velocity: 89 cm/s
Right Internal Carotid Artery/Common Carotid Artery Ratio: 0.8
Right vertebral artery flow is antegrade.
LEFT
Left External Carotid Artery Velocity: 94 cm/s
Left Distal Internal Carotid Artery Velocity: 79 cm/s
Left Distal Common Carotid Artery Velocity: 99 cm/s
Left Internal Carotid Artery/Left Common Carotid Artery Ratio: 0.8
Left vertebral artery flow is antegrade.
Impression RIGHT: RT bulb minimal intimal thickening. RT ECA plaque <10%. Incidental finding: 1 small complex nodule measuring <1cm.
Impression LEFT: LT ECA plaque <10%
Plan: Non-obstructive disease and will intensify medical therapy and Recommend follow-up with Dr. Nourparvar regarding thyroid nodule.

RENAL ARTERY DUPLEX WITH RENAL SIZE & ABDOMINAL AORTA 5/13/2010
Indication: Positive family history of CAD
Peak Systolic Velocity, m/s
Right Renal Left Renal
Proximal Peak Systolic Velocity m/s (<1) .53 .76
Mid Peak Systolic Velocity m/s (<1) .61 .45
Distal Peak Systolic Velocity m/s (<1) .46 .27
Renal Aortic Ratio (<3.5) 0.4 0.5
Renal Length cm (8.5-15) 11.0 11.2
Cortical Thickness cm (>1.1) 1.2 1.5
Parenchymal Flow: ESP present Upper (Yes) Yes Yes
Parenchymal Flow: ESP present Mid (Yes) Yes Yes
Parenchymal Flow: ESP present Lower (Yes) Yes Yes
Resistive index (PSV-EDV/PSV) (<0.70) .67 .63

Duplex Scan of Abdominal Aorta: Date performed: 5/13/2010
Proximal Aortic Diameter 2.2 cm
Mid Aortic Diameter 1.8 cm
Distal Aortic Diameter 1.2 cm
Aortic Peak Systolic Velocity 1.69 m/s
Impression: Normal study

Kidney Ultrasound: Date performed: 5/13/2010
Technique: Using real-time ultrasound and a high-resolution probe, multiple transverse and longitudinal images of both kidneys were obtained.
Findings: Bilateral kidneys appeared normal in size and echogenicity. Right kidney measures 11.0 cm x 4.7 cm x 5.1 cm. Left kidney measures 11.2 cm x 5.3 cm x 4.4 cm. No definite solid masses or hydronephrosis are identified. No free fluid is seen.

Technical Impression: Within normal limits and No Evidence of Renal Artery Stenosis

Duplex Scan of Abdominal Aorta Date: 06/03/2009
Indication: Family history of CAD
Proximal Aortic Diameter: 2.1cm Peak Systolic Velocity:61m/s
Mid Aortic Diameter: 1.8cm Peak Systolic Velocity:46m/s
Distal Aortic Diameter: 1.5cm Peak Systolic Velocity:50m/s
Technical Impression: Negative AAA.

Last colonoscopy: never
Last prostate exam / urological evaluation: 2005-2006. Normal results per patient,
Last PSA:0.40 ng/ml as of 05/05/09
Influenza vaccine declines (11/10/08).

————————————————————————————————————————————————————
DIAGNOSIS/ASSESSMENT:

PALPITATIONS.
Likely related to anxiety and stress. Holter monitoring on 11/11/2008 showed normal sinus rhythm, occasional APCs and occasional VPCs. Normal EKG on 3/20/12. No evidence of mitral valve prolapse on echocardiography. No exercise induced arrhythmias per stress test on 05/07/13. Recommend that the patient avoid alcohol, caffeine and other stimulants, which may precipitate this symptom. He is to contact me or emergency services if this symptom worsens, or he develops new symptoms.

HYPERTENSION.
Controlled. No evidence of left ventricular hypertrophy per echocardiography. Recommend that the patient monitor his blood pressure twice daily and provide me with the records. Target systolic blood pressure in the 110-120 mmHg range recommended. A low salt diet is advised.

DYSLIPIDEMIA.
The patient was advised of the importance of cardiac risk factor modification, including optimal blood pressure, lipid profile, a healthy diet, and daily aerobic exercise. Defer labs and management to his internist.

OTHER:
1. Remote history of syncope in 1991. No recurrence. Likely vasovagal. The patient was advised to rise slowly and to remain well hydrated at all times. He was instructed to contact me if this symptom recurs. Recommend follow up with his internist.
2. Small complex nodule measuring <1cm seen on carotid artery Duplex scan. Recommend follow-up with Dr. Nourparvar.
3. Right inguinal hernia. Recommend use of hernia belt. The patient was advised to avoid heavy lifting. Defer to the patient’s internist/surgeon.

DISCUSSION:

PLAN:
Medication changes: No.

Diet: Patient advised to follow a healthy low fat, salt and carbohydrate diet.

Exercise recommendations: Regular exercise is strongly recommended. Recommend gradual increase in daily aerobic exercise.

Hypertension Instructions: The patient was instructed to monitor their blood pressure twice daily and provide me with the records.

Anxiety recommendations: The patient was advised to practice stress reduction techniques, including but not limited to meditation, deep breathing, yoga and exercise as tolerated.

Preventive Medicine: It is important that the patient follow up with their primary physician for preventative medicine follow ups including yearly prostate exam and annual physical exam.

Follow Up: The patient was advised to return to the office for follow up in 3 weeks or earlier if he has any medical problems.

Emergency recommendations: The patient was advised to call 911 or go to the emergency room if the patient’s condition worsens or does not improve.

——————————————————————————————————————————————————-

Check in time: 07:59 AM Check out time: 08:58 AM

Electronically signed: 07/06/2016 03:49 PM BENZUR, URI

99210 NO CHARGE

Uri M. Ben-Zur, M.D., F.A.C.C.
Interventional Cardiology / Invasive Electrophysiology

18200 Ventura Blvd
Tarzana, CA 91356
Phone (818) 986-0911 Fax (818) 986-9301
Date of visit: 07/05/2016
Reason for Visit:
Requesting Physician:
I had the opportunity to evaluate on the date stated above. I have reviewed the past medical history, symptoms and current therapy. In addition, I have examined the patient and based on my findings have provided my overall impression, outlining my treatment and plans in the summary below.

CHIEF COMPLAINT /HISTORY OF PRESENT ILLNESS:

Ms. is an extremely pleasant 66 year old female with a past medical history of rheumatic heart disease s/p metallic mitral valve replacement and metallic aortic valve replacement, non-obstructive coronaries, non-ischemic cardiomyopathy with severe left ventricular dysfunction, history of persistent atrial fibrillation, s/p A-fib ablation, hypertension, dyslipidemia, and diabetes mellitus type II. She is S/P AV nodal ablation and has developed severe congestive heart failure.

The patient is being seen frequently given labile INR’s.

The patient has a history of occasional shortness of breath with moderate exertion. This symptom has existed for an extended period of time and has been stable. It is mild in severity. No associated symptoms noted.

The patient complains of occasional fatigue. This symptom has existed for an extended period of time and has not changed in severity. It is mild in severity. Rest improves the symptom. No associated symptoms noted.

The patient complains of occasional bilateral leg swelling. It is mild in severity. It is noticeable at the end of the day and resolves by the following morning. No associated symptoms noted.

The patient denies chest pain, palpitations, dizziness, syncope.

Her blood pressure readings have been within normal limits at home. The patient does not follow an exercise program. She does not follow a specific diet.

Overall, states that she is stable.
PAST MEDICAL HISTORY:
Cardiovascular:
Dilated ascending aorta.
Atrial Fibrillation.
Cardiomyopathy, non-ischemic.
Congestive Heart Failure.
Non-obstructive coronaries per cardiac cath 08/26/15.
Dyslipidemia.
Hypertension, benign essential.
Rheumatic heart disease.
Varicose Veins.
H/o mitral valve disorder, s/p metallic mitral valve replacement.
H/o aortic valve disorder, s/p metallic aortic valve replacement.
Respiratory:
Asthma.
Gastroenterology:
Gastritis.
Neurology:
Meningioma, calcified.
Genitourinary:
Nephrolithiasis.
Psychiatry:
Depression.
Hematology/Lymphatic:
Anemia.
Endocrine:
Diabetes mellitus.
H/o Hyperthyroidism. S/p total thyroidectomy.
SURGICAL HISTORY:
Cardiac cath 08/26/15
Mitral valve replacement using a 31-mm St. Jude Medical Valve 01/09/08
Aortic valve replacement using a 31-mm St. Jude Medical Valve 01/09/08
Cholecystectomy.
Hysterectomy and left oophorectomy.
Total thyroidectomy.
ICD implant 01/09/2008
Bone marrow biopsy.
RFA/PVI 10/14/15
RFA/AV node ablation 10/21/15.
breast augmentation.
ICD upgrade, single chamber to biventricular ICD, including explantation of a generator, implantation of a new defibrillator system with a new generator and new transvenous left ventricular lead, ICD testing subclavian venogram. 11/11/15.

CURRENT MEDICATIONS:
1 Lexapro 10 Mg Tablet SIG: take one daily
2 Tylenol With Codeine #3 Tablet 300-30 Mg SIG: half tab PO QD PRN pain
3 Carafate 1 Gm Tablet Gram SIG: one tablet by mouth three times daily.
4 Levothroid 175 Mcg Tablet SIG: one PO QD
5 Phenazopyridine 100 Mg Tab SIG: one PO BID
6 Voltaren 1% Gel SIG: Apply twice daily
7 Miralax Powder 17 Gram/dose SIG: one scoop daily
8 Tramadol Hcl 50 Mg Tablet SIG: take one twice daily as needed for pain
9 Lasix 40 Mg Tablet SIG: BID
10 Metoprolol Succ Er 25 Mg Tab SIG: 1/2 tablet prn bp greater than 130
11 Lorazepam 2 Mg Tablet (Other MD) SIG: 1 Tab PO BID
12 Glimepiride 2 Mg Tablet (Other MD) SIG: half to one tab as needed for BS>130 mg/dL
13 Coumadin 1 Mg Tablet (Other MD) SIG: 7/7/5 mg alt PO QD.
14 Diltiazem 30 Mg Tablet (Other MD) SIG: take one daily occasionally BID
15 Spironolactone 25 Mg Tablet (Other MD) SIG: Take 1 tab by mouth BID. Hold if standing BP < 120 mmHg

ALLERGIES / INTOLERANCES:
ACE Inhibitors, Calcium Channel Blockers, lubiprostone, dexlansoprazole, Proton Pump Inhibitors

SOCIAL HISTORY:
Marital Status: The patient is separated. She has 3 healthy children.
Smoking/tobacco use: No history of smoking.
Alcohol: Non alcoholic beverage drinker.
Recreational drug use: She denies recreational drug use.
Caffeine Intake: She does not drink coffee, tea, soda or any other caffeinated drinks and beverages.
Stress Level: High.
Occupation: Currently retired.

FAMILY HISTORY:
Father is deceased. He died at the age of 83. Cause of death unclear, possibly myocardial infarction.
Mother is deceased. She died at the age of 31. Accidental death.
One brother, healthy.
REVIEW OF SYSTEMS:
Constitutional Symptoms: (+) fatigue.
Constitutional Symptoms: (+) fatigue.
Integumentary: (-) rash, (-) lumps, (-) itching, (-) dryness, (-) acne, (-) discoloration, (-) recurrent skin infections, (-) changes in hair, nails or moles.

Respiratory: (-) cough, (-) hemoptysis, (-) cyanosis, (-) wheezing, (-) nocturnal choking or gasping.

Cardiovascular: (-) chest pain, (-) dizziness, (+) dyspnea with exertion, (+) edema, (-) high blood pressure, (-) palpitations, (-) Syncope.
Cardiovascular: (+) dyspnea with exertion, (+) edema.
Gastrointestinal: gastritis, distended abdomen (+) bloating, (-) change in bowel habits.
Gastrointestinal: gastritis, distended abdomen (+) bloating.
Genitourinary: (-) dysuria, (-) frequency, (-) urgency, (-) hesitancy, (-) polyuria, (-) nocturia, (-) hematuria, (-) urinary incontinence, (-) flank pain, (-) change in urinary habits.

Musculoskeletal: (-) muscle pain, (-) joint pain, (-) bone pain.

Peripheral Vascular: (-) intermittent claudication, (-) cramps, (-) varicose veins, (-) thrombophlebitis.

Neurological: (-) numbness, (-) tingling, (-) tremors, (-) seizures, (-) vertigo, (-) memory loss, (-) any focal or diffuse neurological deficits.

Endocrine: (-) heat or cold intolerance, (-) excessive sweating, (-) excessive thirst, (-) excessive hunger, (-) excessive urination, (-) hirsutism, (-) change in ring or shoe size.

Hematologic/Lymphatic: (-) anemia, (-) easy bruising, (-) excessive bleeding, (-) history of blood transfusions.

PHYSICAL EXAM:
Vitals:

Weight: 164 lbs
Height: 4′ 9”
BMI: 35.49
BSA: 1.73
BP: 138/71(Left Arm)(Standing)
Pulse: 79(Left brachial)(Standing)(Regular)

General Appearance: The patient is an extremely pleasant 66 year old female who looks younger than her stated age. is well developed and well nourished in no apparent distress. Her body habitus is obese. Her mood is mildly depressed. She is short of breath with minimal exertion.
HEENT: Normocephalic and atraumatic. Pupils are equally round and reactive to light and accommodation. Extraocular muscles are intact. Patient’s neck is supple with no jugular venous distention, no carotid bruit was heard and carotid pulses are +2/2. Normal carotid artery upstroke bilaterally. Palpation is not painful and no thyromegaly nor lymphadenopathy can be appreciated.
Respiratory: Clear to auscultation bilaterally without wheezes or rhonchi. No intercostal retractions or accessory muscle use were noted.
Cardiovascular: Regular heart rate and rhythm. Cardiac point of maximal impulse at left fifth intercostal space mid-clavicular line. + S3. Mitral and aortic metallic clicks with II/VI systolic murmur heard. S/p BiVD implantation.
Gastroenterology: Abdomen is soft non-tender and non-distended. Positive bowel sounds, no hepatomegaly or splenomegaly was noted. No bruits were heard.
Extremities: Peripheral pulses were 2+ throughout bilaterally. No cyanosis or clubbing. Lower extremity 3+ edema bilaterally. Minor abrasions over right forearm.
Musculoskeletal: Motor strength is appropriately intact throughout bilaterally. Evidence of 2 inch ecchymosis on left shoulder, signs of healing.
Neurologic: Patient is alert and oriented x3 with deep tendon reflexes appropriately intact throughout bilaterally, non-focal.
Psychiatric: Patient is conscious, cooperative, and well-oriented to time, place, and person. There are no mood swings or psychotic features. Patient’s insight is good. Memory and judgement are intact.
Skin: No skin rash, subcutaneous nodules or ulcers observed. BiVD implant site is clean, without an evidence of infection, bleeding or hematoma.
DIAGNOSTIC DATA:

Encounter long term anticoagulant. Date: Jul 5, 2016.
INR: 1.9.
Current Dose: : 7/7/5 mg PO QD alternating dose.
Therapeutic Goal/INR: 2.5 – 3.5.
Medication adjustments: Increase coumadin to 8 tomorrow only; 7 mg PO QD thereafter.
Next INR test: Jul 8, 2016.

ELECTROCARDIOGRAM: Date performed: May 8, 2016.
Indication: Occasional shortness of breath, history of atypical chest pains, h/o rheumatic heart disease and history of severe valvular heart disease.
Interpretation: Rhythm: A paced with capture.
Conclusion: Abnormal ECG.

2D COLOR DOPPLER ECHOCARDIOGRAPHY:
Date: May 8, 2016 Indication: Recurrent shortness of breath and repeat hospital admissions.

Findings:
Left ventricle:
-LVIDd = 4.4 cm (Men:4.2-5.9 cm/Women: 3.9-5.3cm).
-LVIDs = 3.8 cm (2.0-4.1 cm).
-IVS = 1 cm (0.6-1.1 cm).
-LVPWd = 1.2 cm (0.6-1.1 cm).
Right ventricle: RVSP: 38 mmHg (15-25 mmHg). Increased right ventricular pressure.

Aortic valve: Peak Velocity = 2.2 m/sec (1.0 – 1.7 m/sec).
Mitral valve: Doppler Peak Velocity = 1.7 m/sec; Doppler pressure half-time is 2.8 cm squared.
Tricuspid valve: moderate to severe regurgitation.
Aorta: Ascending aorta: 3.3 cm. ( 2.1-3.4 cm).
IVC 2.8 cm.

Left ventricle ejection fraction: 40 %. Severe LV dysfunction, PSM.

Pericardium: No effusion or calcification.
Pacemaker/ICD lead: ICD lead in right heart.
-Increased Right heart size.
-S/p Metallic MVR, AVR.

CAROTID ARTERY DUPLEX SCAN:
Date of Study: Aug 6, 2015.
Indication: Left carotid bruit.

Measurements:
Left:
CCA distal peak velocity: 82 cm/sec.
CCA end diastolic velocity: 22 cm/sec.
ICA distal peak velocity: 88 cm/sec.
ICA end diastolic velocity: 21 cm/sec.
ECA distal peak velocity: 107 cm/sec.
ECA end diastolic velocity: 18 cm/sec.
Left vertebral artery showed antegrade flow.
ICA/CCA: 1.
Right:
CCA distal peak velocity: 70 cm/sec.
CCA end diastolic velocity: 16 cm/sec.
ICA distal peak velocity: 73 cm/sec.
ICA end diastolic velocity: 23 cm/sec.
ECA distal peak velocity: 89 cm/sec.
ECA end diastolic velocity: 10 cm/sec.
Right vertebral artery showed antegrade flow.
ICA/CCA: 1.

Impression/Comments:

Findings: Bilateral mild plaque.

Plan:
Non-obstructive disease.
Will intensify medical therapy.

LOWER EXTREMITIES VENOUS DOPPLER: Feb 19, 2016.
Indication: 2+ bilateral leg edema.
Impression: Normal venous flow with normal collapse with compression. Normal augmentation of venous flow with calf compression. No evidence of venous insufficiency with valsalva manuever or abdominal pressure. Normal lower extremities.
No evidence of deep venous thrombosis or venous outflow obstruction of the lower extremities by duplex scanning.

RENAL ARTERY-AORTA DUPLEX SCAN: Aug 10, 2015.
Indication: Hypertension (401.1).

Measurements:
Left Renal Peak Systolic Velocity:
Proximal: 0.63 m/s [<1.0].
Mid: 0.58 m/s [<1.0].
Distal: 0.57 m/s [<1.0].
Renal/Aortic Ratio: 0.7. [<3.5].
Right Renal Peak Systolic Velocity:
Proximal: 0.4 m/s [<1.0].
Mid: 0.38 m/s [<1.0].
Distal: 0.34 m/s [<1.0].
Renal/Aortic Ratio: 0.4. [<3.5].

Aorta:
Proximal Aortic Diameter: 2.2 cm.
Mid Aortic Diameter: 1.4 cm.
Distal Aortic Diameter: 1 cm.
Aortic Peak Systolic Velocity: 0.89 m/s.

Kidney:
Left:
kidney length: 12 cm [8.5-15.0 cm].
Kidney Width: 5.1 cm. ( 4.5-5.0 cm].
Kidney Depth (trans): 5.3 cm. [4.5-5.0].
Cortical Thickness: 1.6 cm. [1.1 cm].
Parenchymal Flow /Waveform:
Upper Early Systolic Peak Present.
Mid Early Systolic Peak Present.
Lower Early Systolic Peak Present.
Resistive Index: 0.78 [<0.75] (PSV-EDV/PSV).

Right:
kidney length: 11.5 cm [8.5-15.0 cm].
Kidney Width: 5.3 cm. ( 4.5-5.0 cm].
Kidney Depth (trans): 5.1 cm. [4.5-5.0].
Cortical Thickness: 1.7 cm. [1.1 cm].
Parenchymal Flow /Waveform:
Upper Early Systolic Peak Present.
Mid Early Systolic Peak Present.
Lower Early Systolic Peak Present.
Resistive Index: 0.75 [<0.75]
(PSV-EDV/PSV).

Technical impression:
Within normal limits.

ABDOMINAL AORTA DUPLEX SCAN:
Date: Aug 9, 2015 Indication: Indication: Hypertension (401.1).

Aorta:
Proximal Aortic Diameter: 1.9 cm.
Proximal Aortic Peak Systolic Velocity: 1.35 m/s.
Mid Aortic Diameter: 1.5 cm.
Mid Aortic Peak Systolic Velocity: 0.91 m/s.
Distal Aortic Diameter: 0.9 cm.
Distal Aortic Peak Systolic Velocity: 1.24 m/s.

Technical impression:
Within normal limits.
Mild plaque seen in abdominal aorta.

ICD INTERROGATION REPORT: Date of Interrogation: Jul 5, 2016.
Implant date: 9/21/2015.
Model: MDT DTBA1QQ.
Battery status: 2.98 V.
Estimated battery life: 3.6 years.

Right Ventricular sensitivity: 4.8 mV.
Right Ventricular threshold: 1.75 V at 0.40 ms.
Right Ventricular impedance: 340 Ohms.

Left Ventricular sensitivity: 4.8 mV.
Left Ventricular threshold: 0.87 V at 1.2 ms.
Left Ventricular impedance: 340 Ohms.
Ventricular pacing: 99 %.

Final Parameters:
Mode: VVIR.
Lower rate: 70 bpm.
Upper rate: 120 bpm.
Right Ventricular sensitivity: 0.30 mV.
Right Ventricular threshold: 3.75 V at 0.4 ms.
Left Ventricular threshold: 1.25 V at 1.2 ms.
Parameter changes: None.
Underlying rhythm: Atrial Fibrillation.
Current rhythm: BIV Paced.

Interrogation Assessment: Device function normal, No arrhythmia recorded.

Possible fluid accumulation in February 2016. (Optivol).
Normal device Function, Normal Corvue Trend (drop).
REGADENOSON MYOCARDIAL PERFUSION PET: PET Adenosine
Date: 08/13/2015
Indication: Abnormal ECG, CHF, shortness of breath and atypical chest pain
Impression: The test results indicate a high (>90%) likelihood for the presence of jeopardized myocardium. LCX: a medium sized reversible defect in the lateral wall.
Incidental findings from CT scan performed as part of the procedure:
– Mild coronary atherosclerosis.

Cardiac Catheterization: 08/26/15:
DATE: 08/26/2015
08/26/15:
– Left main was non obstructed.
– Left anterior descending and circumflex arteries were non obstructed.
– The right coronary artery was non obstructed.
– The decision was made not to perform LV angiography because the patient has valves in the Mitral and aortic position.
– Of note, fluoroscopically, the patient had a single chamber VVI pacemaker. The ventricular lead was in the area of the apical septum, and the patient also had metallic aortic and mitral valve prosthesis.

ULTRASOUND OF LIVER AND GALLBLADDER: 08/11/15
Indication: Increased LFTs, h/o abdominal pain
Normal liver and CBD.
Comment: Study was within normal limits. The patient has a h/o cholecystectomy.
F/u with Dr. Jacobs recommended.

Urinalysis Report: Date: Nov 12, 2015.
Indication: Dysuria.
Leukocytes: Small amount of Leukocytes present.
Nitrite: Negative.
Urobilinogen: (Normal 0.2 – 1).
Protein: Trace amount present.
Ph: 6.
Blood: Negative Non-Hemolyzed blood present.
Specific Gravity: 1.020.
Ketone: Moderate.
Bilirubin: Moderate.
Glucose: Negative.

Colonoscopy: Last colonoscopy was performed in 2015 Results were normal.
Endoscopy: 2015.
Mammogram: Last mammogram was performed in 2015.

————————————————————————————————————————————————————
DIAGNOSIS/ASSESSMENT:

SHORTNESS OF BREATH/FATIGUE/LEG EDEMA.
NON-ISCHEMIC CARDIOMYOPATHY.
CONGESTIVE HEART FAILURE. NYHA CLASS III-IV.
S/p BiVD upgrade on 11/11/15.
Lexi scan on 05/27/16 showed a low likelihood of jeopardized myocardium. Left ventricle ejection fraction of 30 %, severe LV dysfunction per echocardiography. Normal Optivol per device interrogation. Continue diuretic therapy. The patient was advised of the importance of following a healthy diet, weight loss and daily aerobic exercise. She is to contact me or emergency services if her symptoms worsen, or she develops new symptoms.

H/O PERSISTENT ATRIAL FIBRILLATION WITH PAROXYSMS OF RAPID VENTRICULAR RESPONSE.
S/p EPS/AV NODE ABLATION on 10/21/15.
The patient is on anticoagulation therapy. The patient was advised to avoid alcohol, caffeine and other stimulants which may precipitate her condition. She was instructed to contact me if she develops palpitations.

RHEUMATIC HEART DISEASE.
S/P MITRAL VALVE & AORTIC VALVE REPLACEMENT.
Normally functioning mechanical mitral and aortic valves. The patient is on lifelong anticoagulation therapy. Will follow with serial imaging.

BiVD IN SITU.
Normal device function per interrogation.

TRICUSPID VALVE DISORDER/PULMONARY HYPERTENSION.
Moderate to severe tricuspid valve regurgitation with RVSP 38 mmHg per echocardiography. Will follow with serial imaging.

HYPERTENSION.
Controlled. The patient was informed that a healthy lifestyle has been shown to effectively reduce BP and decrease the risk of cardiovascular disease. The patient was educated on the importance of low sodium diet and a daily aerobic exercise program. Optimal blood pressure, with target sBP of 110-120mmHg advised.

DIABETES MELLITUS TYPE II.
HbA1c 6.5% on 04/26/16. Low carbohydrate, healthy diet advised. Defer management to her internist.

DYSLIPIDEMIA.
HDL 40 mg/dL, LDL 62 mg/dL, triglycerides 68 mg/dL per labs on 06/10/16. Low fat, healthy diet advised.

S/p MECHANICAL FALL on 04/15/16.
Normal device function per interrogation. The patient was advised to rise slowly from a lying down/seated position, and remain well hydrated at all times. She is to contact me if she develops dizziness.

OTHER:
– Recurrent lower abdominal pain, unclear etiology. She is under the care of Dr. Jacobs of gastroenterology. Will defer work up to Dr. Jacobs.
– Pruritus. Unclear etiology. Recommend evaluation by Dr. Hartmann of dermatology. The patient was provided with the appropriate referral information.
– Depression/Insomnia/Anxiety. Recommended practicing relaxation techniques.
– The patient has a history of a large calcified meningioma. Repeat CT scan in one year is recommended.
– Hypothyroidism. TSH 1.16 mIU/L on 06/10/16. The patient is on Levothyroxine. Will follow with serial labs.
– H/o Recurrent UTIs. Followed by Dr. Arieh Bergman.
– Anemia. Followed by Dr. Levon Qasabian.
– Back and knee pain. The patient was referred for physical therapy.

DISCUSSION:

PLAN:
Medication changes:
Take one time dose of Coumadin 8 mg PO, and then 7 mg PO QD thereafter.

Procedures performed today: INR, ICD complete interrogation.

Diet: Patient advised to follow a healthy low fat, salt and carbohydrate diet.

Exercise recommendations: Regular exercise is strongly recommended. Patient is advised to lose weight.

Hypertension Instructions: The patient was instructed to monitor their blood pressure twice daily and provide me with the records. Patient educated to limit their salt intake.

Anxiety recommendations: The patient was advised to practice stress reduction techniques, including but not limited to meditation, deep breathing, yoga and exercise as tolerated.

Follow Up: The patient was advised to return to the office for follow up in 3 days or earlier if she has any medical problems.

Emergency recommendations: The patient was advised to call 911 or go to the emergency room if the patient’s condition worsens or does not improve.

REFERRAL: Please follow up with Dr. Barnes of gynecology.

——————————————————————————————————————————————————-
1 Coumadin 1 Mg Tablet SIG: 7 mg PO QD REF: 3

Changed/Discontinued Medication(s):
Changed: COUMADIN 1 MG TABLET
Discontinued By Other MD: COREG 3.125 MG TABLET
Changed By Other MD: COUMADIN 1 MG TABLET
Discontinued By Other MD: Creon capsule
Changed By Other MD: DILTIAZEM 30 MG TABLET
Discontinued By Other MD: MELOXICAM 15 MG TABLET
Changed By Other MD: SPIRONOLACTONE 25 MG TABLET
Check in time: 08:03 AM Check out time: 09:14 AM

Electronically signed: 07/06/2016 03:26 PM BENZUR, URI

G8427 Med.with dosage and verification documented; 1036F CURRENT TOBACCO NON-USER CAD CAP COPD PV DM; 85610 Prothrombin time; 93290 OPT CHECK; 93289 Analyze cardio/defib dual w/o reprg; 99213 Office/outpatient visit, est, mod; G8419 BMI abnormal. No followup plan documented

Uri M. Ben-Zur, M.D., F.A.C.C.
Interventional Cardiology / Invasive Electrophysiology

18200 Ventura Blvd
Tarzana, CA 91356
Phone (818) 986-0911 Fax (818) 986-9301
Date of visit: 07/05/2016
Reason for Visit:
Requesting Physician:
I had the opportunity to evaluate on the date stated above. I have reviewed the past medical history, symptoms and current therapy. In addition, I have examined the patient and based on my findings have provided my overall impression, outlining my treatment and plans in the summary below.

CHIEF COMPLAINT /HISTORY OF PRESENT ILLNESS:

Ms. is an extremely pleasant 74 year old female with a past medical history of CAD s/p CABG in 2005, Congestive heart failure, Atrial fibrillation s/p RFA/ PVI on 5/21/2014 and sick sinus syndrome s/p permanent pacemaker implantation on 08/29/2012, carotid artery disease s/p carotid endarterectomy of the right carotid in 2005, CVA of the left hemisphere in 11/28/2011, hypertension, hyperlipidemia, diabetes mellitus type II, and hypothyroidism. She is accompanied today by husband.

The patient was admitted to Sherman Oak rehab for leg weakness for about one month by Dr. Yadegar (818)986-7424 The patient is currently living at the Four Seasons Healthcare and Wellness Center. She was previously admitted to PTMC ER on 04/25/16 given moderate to severe left hip pain. ER work-up including X-rays negative for any signs of fracture dislocation. Given recent angiogram, left groin ultrasound was performed which did not show any signs of significant hematoma, abscess. No bruits noted be concerning for fistula. Her condition was thought to be likely musculoskeletal.

The patient denies chest pain, palpitations, dizziness, syncope.

Her blood pressure readings have been elevated above her usual baseline lately. Her blood sugar levels range 120 to 140 mg/dL according to her home monitor. Ms. GALLARDO DE is following an exercise program. She follows a healthy diet.

The patient is on chronic anticoagulation therapy. Her last INR was 2.3 on Jun 7, 2016.

Overall, states that she is stable.
PAST MEDICAL HISTORY:
Cardiovascular:
Atrial Fibrillation.
Atrial Flutter.
Carotid artery disease.
Congestive Heart Failure.
Coronary Artery Disease.
Hyperlipidemia.
Hypertension, benign essential.
Altered level of consciousness on 09/19/12 because of severe hypoglycemia due to hypoglycemic agents.
Neurology:
Cerebrovascular accident 11/2011.
Endocrine:
Hypothyroidism.
SURGICAL HISTORY:
Carotid Endarterectomy right, 2005.
Coronary artery bypass graft (2005).
Pacemaker implant 08/29/2012. MEDTRONIC
Pulse generator model RVDR01, serial # PTN226595H
Right atrial lead model #5086MR152, serial # LFP159085V
Right ventricular lead model # 5086MR158, serial # LFP71457V.
S/p Pulmonary vein isolation with entrance and exit block. Ablation of the entire posterior wall, anterior roof area, resulting in termination of fibrillation into flutter. Additional driver of fibrillation in the coronary sinus, status post ablation. Additional ectopic rhythm coming from the above-mentioned area
consistent with focal ectopic atrial tachycardia. Mitral isthmus flutter. Successful termination of flutter with anterior isthmus line with bidirectional block. Roof-dependent flutter with creation of bidirectional block on the roofline. Additional ablation, cavotricuspid isthmus, with bidirectional block, 05/21/2014.
S/p comprehensive electrophysiology study, status post radiofrequency ablation of atrial fibrillation/cardioversion/successful pulmonary vein isolation 11/04/15, 04/16/16.

CURRENT MEDICATIONS:
1 Levothyroxine 112 Mcg Tablet SIG: 1 tab PO QD Tuesday-Sunday, HOLD on Mondays
2 Potassium Cl Er 20 Meq Tablet SIG: PO QD
3 Lasix 20 Mg Tablet SIG: Take 1/2 tab by mouth once daily
4 Bystolic 20 Mg Tablet SIG: Take 1 tablet PO QD.
5 Glipizide 5 Mg Tablet SIG: one tablet PO QD
6 Metformin Hcl 500 Mg Tablet (Other MD) SIG: Take 1 tab PO BID
7 Coumadin 1 Mg Tablet (Other MD) SIG: decrease 1mg qd

ALLERGIES / INTOLERANCES:
Statins-Hmg-Coa Reductase Inhibitors, Amiodarone, Biguanides

FAMILY HISTORY:
The patient’s father is deceased.
The patient’s mother is deceased. She died at the age of 38 due to cardiac arrest/MI.
The patient has 5 daughters. 2 with DM.
The patient had two sons. One died of a myocardial infarction/cardiac arrest at 40.
REVIEW OF SYSTEMS:
Constitutional Symptoms: (-) fever, (-) chills, (-) night sweats, (-) fatigue, (-) weakness, (-) changes in appetite or weight.

Integumentary: (-) rash, (-) lumps, (-) itching, (-) dryness, (-) acne, (-) discoloration, (-) recurrent skin infections, (-) changes in hair, nails or moles.

Respiratory: (-) cough, (-) hemoptysis, (-) cyanosis, (-) wheezing, (-) nocturnal choking or gasping.

Cardiovascular: (-) chest pain, (-) dizziness, (+) dyspnea with exertion, (+) edema, (+) high blood pressure, (-) palpitations, (-) shortness of breath.
Cardiovascular: (+) dyspnea with exertion, (+) edema, (+) high blood pressure.
Gastrointestinal: (-) abdominal pain, (-) heartburn, (-) constipation, (-) diarrhea, (-) nausea, (-) vomiting, (-) hematochezia, (-) melena, (-) change in bowel habits.

Genitourinary: (-) dysuria, (-) frequency, (-) urgency, (-) hesitancy, (-) polyuria, (-) nocturia, (-) hematuria, (-) urinary incontinence, (-) flank pain, (-) change in urinary habits.

Musculoskeletal: (+) joint pain, (-) stiffness.
Musculoskeletal: (+) joint pain.
Peripheral Vascular: (-) intermittent claudication, (-) cramps, (-) varicose veins, (-) thrombophlebitis.

Neurological: (-) numbness, (-) tingling, (-) tremors, (-) seizures, (-) vertigo, (-) memory loss, (-) any focal or diffuse neurological deficits.

Endocrine: (-) heat or cold intolerance, (-) excessive sweating, (-) excessive thirst, (-) excessive hunger, (-) excessive urination, (-) hirsutism, (-) change in ring or shoe size.

Hematologic/Lymphatic: (-) anemia, (-) easy bruising, (-) excessive bleeding, (-) history of blood transfusions.

PHYSICAL EXAM:
Vitals:
BP: 150/57(Left Arm)(Standing)
Pulse: 80(Left brachial)(Standing)(Regular)

Weight: 129 lbs
Height: 5′
BMI: 25.19
BSA: 1.57
BP: 158/54(Left Arm)(Supine)
Pulse: 80(Left brachial)(Supine)(Regular)

General Appearance: The patient is an extremely pleasant 74 year old female who looks younger than her stated age. She is well developed and well nourished in no apparent distress. Her body habitus is overweight, her mood is normal.
HEENT: Normocephalic and atraumatic. Pupils are equally round and reactive to light and accommodation. Extraocular muscles are intact. Patient’s neck is supple with no jugular venous distention, right carotid bruit was heard and carotid pulses are +2/2. Normal carotid artery upstroke bilaterally. Palpation is not painful and no thyromegaly nor lymphadenopathy can be appreciated.
Respiratory: Clear to auscultation bilaterally without wheezes or rhonchi. No intercostal retractions or accessory muscle use were noted.
Cardiovascular: Regular heart rate and rhythm. Cardiac point of maximal impulse at left fifth intercostal space mid-clavicular line. Grade III/VI systolic and diastolic murmur. S1 and S2 noted. No rubs, clicks, thrills or gallops noted.
Gastroenterology: Abdomen is soft non-tender and non-distended. Positive bowel sounds, no hepatomegaly or splenomegaly was noted. No abdominal bruits. No rebound tenderness or guarding present.
Extremities: Lower extremity edema, 3+ left leg, 1+ right leg. Pulses were 2+ throughout bilaterally. No cyanosis or clubbing.
Musculoskeletal: Motor strength is appropriately intact throughout bilaterally.
Neurologic: Patient is alert and oriented x3 with deep tendon reflexes appropriately intact throughout bilaterally, non-focal.
Psychiatric: Patient is conscious, cooperative, and well-oriented to time, place, and person. There are no mood swings or psychotic features. Patient’s insight is good. Memory and judgement are intact.
Skin: No skin rash, subcutaneous nodules, lesions or ulcers observed.
DIAGNOSTIC DATA:

Encounter long term anticoagulant. Date: Jul 5, 2016.
INR: 2.2.
Current Dose: : 1 mg daily.
Therapeutic Goal/INR: 2.0 – 3.0.
Medication adjustments: Increase coumadin to 2/1.5/1.5/1.5.
Next INR test: Jul 8, 2016.

CHAD2DS SCORE:
Congestive Heart Failure: 1 point.
Hypertension 1 point.
Diabetes Mellitus: 1 point.
H/O STROKE/TIA/THROMBO-EMBOLISM: 2 points.
Vascular Disease: 1 point.
Age 65-74: 1 point.
Female Gender: 1 point.
Total Score: . Antithrombotic therapy is recommended for stroke prevention.

BLEEDING RISK/HAS-BLED SCORE:
HYPERTENSION: 1 point.
H/O Stroke: 1 point.
Age over 65: 1 point.
Total score: 3. (3.74% risk is for intracranial bleed, bleed requiring hospitalization or a hemoglobin drop > 2g/L or that needs transfusion).

HIGH RISK PATIENT: A score of 3 or more indicates increased one year bleed risk on anticoagulation. The patient needs to be seen frequently for anticoagulation surveillance.

ELECTROCARDIOGRAM: Date performed: Dec 7, 2015.
Indication: Occasional shortness of breath, 3/6 Systolic murmur. H/o valvular heart disease.
Interpretation: Rhythm: A Paced with V Sensed; Left Ventricular Hypertrophy with associated ST changes.
Conclusion: Abnormal ECG.

Rhythm Strip.
Date: 09/25/12.
Indication: check QT on Amiodarone.
QT=0.44 ms.

2D COLOR DOPPLER ECHOCARDIOGRAPHY:
Date: Dec 7, 2015 Indication: Occasional shortness of breath, 3/6 Systolic murmur. Evaluate Aortic Stenosis.

Findings:
Left atrium: Dimension: 4.3 cm. (Men: 3-4 cm/Women: 2.7-3.8 cm). It is mildly dilated.
Left ventricle:
-LVIDd = 3.6 cm (Men:4.2-5.9 cm/Women: 3.9-5.3cm).
-LVIDs = 3.1 cm (2.0-4.1 cm).
-IVS = 1.5 cm (0.6-1.1 cm).
-LVPWd = 1.6 cm (0.6-1.1 cm).
Ventricular thickness: There is moderate LV concentric hypertrophy.

Right atrium: Normal in size and shape and shows no signs of ASD, mass or thrombus.
Right ventricle: RVSP: 47 mmHg (15-25 mmHg).
Pulmonary Artery: There is moderate pulmonary hypertension.

Aortic valve: Peak Velocity = 2.4 m/sec (1.0 – 1.7 m/sec). Mild insufficiency. No sclerosis. Mild to moderate aortic valve stenosis.
Mitral valve: Mild regurgitation. No sclerosis. No stenosis. No valve prolapse.
Tricuspid valve: Moderate regurgitation. No sclerosis. No stenosis. No vegetations noted.
Pulmonic valve: Normal pulmonic valve.
Aorta: Ascending aorta: 4.1 cm. ( 2.1-3.4 cm), Dilated ascending aorta.

Left ventricle ejection fraction: 60 %.

Pericardium: No effusion or calcification.
Venous: Inferior vena cava: Normal diameter with normal respiratory variation.

TREADMILL STRESS TEST/W STRESS ECHOCARDIOGRAPHY.
Date: Jan 23, 2015. Indication: Occasional shortness of breath, Non-specific ST-T changes, Abnormal EKG
Risk and benefits of exercise stress test including but not limited to myocardial infarction, vascular compromise and death were explained to Ms. GALLARDO DE in detail. The patient asked appropriate questions. All questions were answered. The patient wished to proceed and gave her informed consent.

Protocol: Standard Bruce protocol.

Procedure:
STAGE I (Min 0 to 2:50): Min: 1 . MPH: 1.7. Grade: 10 %. MET: 1-5. BP: 140/90, Pulse: 115, O2 Sat: 98.

Results:
Maximal Predicted Heart Rate: 147 bpm.
Peak heart rate achieved: 94 bpm.
Maximal heart rate achieved: 64 % of predicted heart rate.
Average O2 saturation throughout the study: 98 %.
Total Minutes: 2.30.
Reason for stopping: Generalized fatigue.

Clinical response:
Peak exercise electrocardiogram revealed positive ST-T changes – resolved 2 minutes into recovery.

Stress echocardiography:
Revealed normal left ventricular function at rest with an adequate increase in left ventricular function in response to exercise.

Findings:
Left ventricle:
-IVS = 1.2 cm (0.6-1.1 cm).
-LVPWd = 1.1 cm (0.6-1.1 cm).
Ventricular thickness: There is mild LV concentric hypertrophy.

Aortic valve: S/P Aortic valve replacement.

Left ventricle ejection fraction: 60 %.

Summary: The patient exercised according to the BRUCE protocol for a total of 2.30 minutes, achieving a peak heart rate of 94 bpm, 64% of the maximum predicted heart rate. The electrocardiogram showed ST-T changes as mentioned above. Atrial premature contractions/ventricular premature contractions/dysrhythmias were not seen.
Blood pressure response to exercise was normal at 140/90 mmHg.
The study was inconclusive.

Conclusion:
Response to exercise: Stress testing performed was inconclusive given that the target exercise time duration was not achieved and that the maximal target heart rate was not achieved.
There is no evidence of inducible ischemia at the level of exercise achieved.
No evidence of stress induced arrhythmias at the level of exercise achieved.
Probability of obstructive coronary artery disease: Inconclusive.

Recommendations: Recommend increasing exercise program and repeat stress test in 3-6 months.

Holter Monitoring 24hrs: Hookup Date: Aug 26, 2012..
Indication: evaluation of fainting.
Findings:
Sinus bradycardia at 39 beats per minute, paroxysmal atrial fibrillation at 167 beats per minute.
Conclusions: Recurrent tachycardia-bradycardia/sick sinus syndrome.
Recommend permanent pacemaker implantation.

CAROTID ARTERY DUPLEX SCAN:
Date of Study: Jan 15, 2016.
Indication: History of severe carotid artery disease, Left carotid bruit.

Measurements:
Left:
CCA distal peak velocity: 80 cm/sec.
CCA end diastolic velocity: 13 cm/sec.
ICA distal peak velocity: 164 cm/sec.
ICA end diastolic velocity: 44 cm/sec.
ECA distal peak velocity: 101 cm/sec.
ECA end diastolic velocity: 10 cm/sec.
Left vertebral artery showed antegrade flow.
ICA/CCA: 2.1.
Right:
CCA distal peak velocity: 63 cm/sec.
CCA end diastolic velocity: 9 cm/sec.
ICA distal peak velocity: 120 cm/sec.
ICA end diastolic velocity: 30 cm/sec.
ECA distal peak velocity: 77 cm/sec.
ECA end diastolic velocity: 4 cm/sec.
Right vertebral artery showed antegrade flow.
ICA/CCA: 1.9.

Impression/Comments:
Left:
Left bulb plaque: less than 30%.
Left CCA: plaque 20%.
Left ICA: Moderate Stenosis (50-60%).
Right:
Right bulb plaque: 20%.

LOWER EXTREMITIES VENOUS DOPPLER: May 12, 2016.
Indication: +1 right leg edema, 2+ left leg edema.
Impression: Normal venous flow with normal collapse with compression. Normal augmentation of venous flow with calf compression. No evidence of venous insufficiency with valsalva manuever or abdominal pressure. Normal lower extremities. The Doppler signals were phasic with good augmentation.
The images showed widely patent veins that were fully compressible.
No evidence of deep venous thrombosis or venous outflow obstruction of the lower extremities by duplex scanning.

RENAL ARTERY-AORTA DUPLEX SCAN: Apr 17, 2015.
Indication: Uncontrolled hypertensive heart disease without heart failure (402.00) History of renal cysts.

Measurements:
Left Renal Peak Systolic Velocity:
Proximal: 0.43 m/s [<1.0].
Mid: 0.44 m/s [<1.0].
Distal: 0.59 m/s [<1.0].
Renal/Aortic Ratio: 0.5. [<3.5].
Right Renal Peak Systolic Velocity:
Proximal: 0.51 m/s [<1.0].
Mid: 0.55 m/s [<1.0].
Distal: 0.6 m/s [<1.0].
Renal/Aortic Ratio: 0.5. [<3.5].

Aorta:
Proximal Aortic Diameter: 2.3 cm.
Mid Aortic Diameter: 1.3 cm.
Distal Aortic Diameter: 0.9 cm.
Aortic Peak Systolic Velocity: 1.18 m/s.

Kidney:
Left:
kidney length: 9.1 cm [8.5-15.0 cm].
Kidney Width: 3.5 cm. ( 4.5-5.0 cm].
Kidney Depth (trans): 4 cm. [4.5-5.0].
Cortical Thickness: 1.2 cm. [1.1 cm].
Parenchymal Flow /Waveform:
Upper Early Systolic Peak Present.
Mid Early Systolic Peak Present.
Lower Early Systolic Peak Present.
Resistive Index: 0.81 [<0.75] (PSV-EDV/PSV).

Right:
kidney length: 8.1 cm [8.5-15.0 cm].
Kidney Width: 3.5 cm. ( 4.5-5.0 cm].
Kidney Depth (trans): 4.5 cm. [4.5-5.0].
Cortical Thickness: 1.1 cm. [1.1 cm].
Parenchymal Flow /Waveform:
Upper Early Systolic Peak Present.
Mid Early Systolic Peak Present.
Lower Early Systolic Peak Present.
Resistive Index: 0.77 [<0.75]
(PSV-EDV/PSV).

Findings: Left kidney 1.8 x 1.4 x 1.5cm complex cyst. No change in comparison with prior study.

Technical impression: .

ABDOMINAL AORTA DUPLEX SCAN:
Date: Jan 17, 2014 Indication: Indication: Hypertension (401.1) and abdominal bruit.

Aorta:
Proximal Aortic Diameter: 1.9 cm.
Proximal Aortic Peak Systolic Velocity: 0.79 m/s.
Mid Aortic Diameter: 1.4 cm.
Mid Aortic Peak Systolic Velocity: 0.77 m/s.
Distal Aortic Diameter: 0.8 cm.
Distal Aortic Peak Systolic Velocity: 1.4 m/s.

Technical impression:
Within normal limits.
Mild plaque seen in abdominal aorta.

QUICK CHECK. Date: 05/12/16
Indication:shortness of breath. S/P AVN ablation
Impression: Normal device function.
REGADENOSON MYOCARDIAL PERFUSION PET: Date: 06/14/2013
Indication: Shortness of breath
Impression: The test results indicate a low (<10%) likelihood for the presence of jeopardized myocardium. The mildly decreased myocardial flow reserve of 1.75 (normal >2.0) suggests increased risk of cardiac hard events.

ULTRASOUND OF LIVER AND GALLBLADDER:

Other: ABDOMINAL ULTRASOUND
DATE: 04/25/2016
INDICATION: Abdominal pain
IMPRESSIONS: The study shows one complex cyst seen in the left kidney measuring 1.8cm and one nephrolithiasis measuring less than 1cm. Unable to visualize gallbladder. Refer to ER (PTMC) as soon as possible.

Test: Exam: CT Code Brain Exam Date: 09/19/12
IMPRESSION:
Intracranial calcification is suspicious for inactive cysticercosis. Atrophy. Deep white matter disease. No acute intracranial abnormalities. Left maxillary retention cyst.

FLU VACCINATION: Aug 30, 2015.

————————————————————————————————————————————————————
DIAGNOSIS/ASSESSMENT:

H/O ATRIAL FLUTTER AND RECURRENT PAROXYSMAL ATRIAL FIBRILLATION WITH PAROXYSMAL RAPID VENTRICULAR RATES.
S/p EPS/RFA on 04/20/16. In-house INR today was 2.9. Continue Coumadin therapy at 1 mg PO QD.

SHORTNESS OF BREATH.
Mild. Stable. Multifactorial. Patient with a history of severe coronary artery disease, valvular heart disease, arrhythmias. EKG revealed A paced with V sensed, and LVH with associated ST-T changes. Echocardiography revealed moderate tricuspid valve regurgitation, mild mitral valve regurgitation, mild to moderate aortic valve stenosis, moderate pulmonary hypertension, EF 60%. Low likelihood of angiographically significant coronary artery disease per myocardial perfusion scanning. The patient was advised to contact me or emergency services if this symptom worsens, or she develops new symptoms.

LOWER EXTREMITY EDEMA
Left leg worse than right. No evidence of lower extremities venous insufficiency or deep vein thrombosis per Duplex scan. The patient was advised to elevate her legs above heart level for 15-20 minutes 3-4 times per day as needed. Low salt diet advised.

H/O RECURRENT ACUTE CONGESTIVE HEART FAILURE.
Secondary to atrial fibrillation with uncontrolled ventricular response. Pro BNP 2878 pg/mL per labs on 04/19/16 at PTMC. The patient is on diuretic therapy. Low salt diet advised.

CORONARY ARTERY DISEASE.
Adenosine Myocardial Perfusion PET Rubidium scan performed on 06/14/13 revealed low likelihood of angiographically significant disease. The patient was advised of the importance of cardiac risk factor modification, including optimal blood pressure, lipid profile, a healthy diet, weight loss and daily aerobic exercise.

H/O RECURRENT TACHY-BRADY DYSRHYTHMIAS/SICK SINUS SYNDROME
PACEMAKER IN SITU (since 08/29/12).
Normal device function per interrogation.

PAROXYSMAL VENTRICULAR TACHYCARDIA.
No recurrence noted. Recommend that the patient avoid alcohol, caffeine, and other stimulants, which may precipitate her condition.

VALVULAR DISORDERS/PULMONARY HYPERTENSION.
Mild to moderate aortic valve stenosis with mild insufficiency, mild mitral valve regurgitation, moderate tricuspid valve regurgitation, RVSP 47 mmHg per echocardiography. Will follow with serial imaging.

DILATED ASCENDING AORTA.
Ascending aorta 4.1 cm per echocardiography. Optimal blood pressure, and lipid profile recommended. Will follow with serial imaging and manage her hypertension.

H/O CVA/ H/O CAROTID ARTERY DISEASE.
S/p left-hemispheric cerebrovascular accident on 11/28/11. S/p right carotid endarterectomy in 2005. Moderate left ICA stenosis per carotid Duplex scan as outlined above. Defer management to her neurologist.

HYPERTENSION.
Moderate concentric left ventricular hypertrophy per echocardiography. Recommend that the patient continue to monitor her blood pressure twice daily and provide me with the records. Target systolic blood pressure in the 110-120 mmHg range recommended. Low salt, healthy diet advised. She may need

DIABETES MELLITUS.
Defer management to her internist, Dr. Rose.

DYSLIPIDEMIA.
HDL 14 mg/dL, LDL 52 mg/dL per labs on 05/12/16. Atorvastatin was discontinued given elevated LFTs. Low fat, healthy diet advised.

OTHER:
– HYPOTHYROIDISM. TSH elevated at 13.74 mg/dL per labs on 05/12/16. The patient is on Levothyroxine. Defer management to Dr. Rose.
– RENAL CYST. 1 Complex cyst with vascularity seen in the left kidney per renal ultrasound. Unchanged compared with previous study. Recommend follow up with Dr. Navon.
– Hyperuricemia. Uric acid 9.2 mg/dL per labs on 1/28/16. Defer management to Dr. Rose.
– Hyponatremia, serum Na 134 mmol/L on 06/07/16. Recommend limiting free water intake to 1L/day. Will follow with serial labs.
– H/o hypokalemia. resolved. Potassium 4.0 mmol/L per labs on 06/10/16. The patient is on supplemental Potassium. Will follow with serial labs.
– Elevated alk phs, 155 U/L, elevated bilirubin 1.8 mg/dL, unclear etiology. Recommend follow up with Dr. Jacobs of gastroenterology.
– Anemia. Defer work up and management to her internist.
– Thrombocytopenia. Platelet count 116 thou/uL per labs on 06/10/16. Will follow with serial labs and consider referral to a hematologist depending on her clinical progress.

DISCUSSION:

PLAN:
Increase coumadin to 2/1.5/1.5/1.5.

Procedures performed today: INR.

Diet: Patient advised to follow a healthy low fat, salt and carbohydrate diet.

Exercise recommendations: Regular exercise is strongly recommended.

Hypertension Instructions: The patient was instructed to monitor their blood pressure twice daily and provide me with the records. She was told to check her blood pressures before taking her medications, once in the morning and once in the evening.

Leg edema recommendations: The patient was advised to raise their legs over heart level for 30 minutes 3 times a day.

Follow Up: The patient was advised to return to the office for follow up in 1 week or earlier if she has any medical problems.

Emergency recommendations: The patient was advised to call 911 or go to the emergency room if the patient’s condition worsens or does not improve.

——————————————————————————————————————————————————-

Check in time: 08:21 AM Check out time: 08:59 AM

Electronically signed:

Uri M. Ben-Zur, M.D., F.A.C.C.
Interventional Cardiology / Invasive Electrophysiology

18200 Ventura Blvd
Tarzana, CA 91356
Phone (818) 986-0911 Fax (818) 986-9301
Date of visit: 07/05/2016
Reason for Visit:
Requesting Physician:
I had the opportunity to evaluate on the date stated above. I have reviewed the past medical history, symptoms and current therapy. In addition, I have examined the patient and based on my findings have provided my overall impression, outlining my treatment and plans in the summary below.

CHIEF COMPLAINT /HISTORY OF PRESENT ILLNESS:

s an extremely pleasant 89 year old male with a past medical history of coronary artery disease and valvular heart disease, s/p aortic valve replacement and CABG in January 2001 s/p cardiac catheterization on 9/19/12. He also has a history of hypertension, dyslipidemia.

The patient presents to clinic today due to lower extremity pain. It is bilateral, musculoskeletal in nature, occurs during the night and wakes him up from his sleep. The pain resolves with walking.

The patient denies chest pain, shortness of breath, palpitations, dizziness, syncope.

His blood pressure readings have been within normal limits at home 120/60. Mr. GOLDBERG is following an exercise program. Exercises at the complex and walks. He follows a healthy diet.

At the time of his last visit, no medication changes were made.
PAST MEDICAL HISTORY:
Cardiovascular:
Aortic Stenosis. Diagnosed January 2001. S/p bioprosthetic aortic valve replacement.
Claudication.
Coronary Artery Disease.
Dyslipidemia.
Hypertension, benign essential.
Peripheral Vascular Disease.
Genitourinary:
Benign Prostatic Hyperplasia.
SURGICAL HISTORY:
Aortic valve replacement Jan 2001
left heart catheterization, Left Subclavian artery angiography, LIMA angiography on 03/30/16.
Coronary angiogram (09/19/12).
Coronary artery bypass graft (2001).
Cardiac cath 08/20/14
Lower extremity angiography/angioplasty 09/26/14.
LVAD – IMPLELLA INSERTION, PTCA/DE STENT (4.0x18mm Xience Alpine) SFV GRAFT (TO OM) on 04/06/16.

CURRENT MEDICATIONS:
1 Plavix 75 Mg Tablet SIG: Take 1 tab by mouth once daily
2 Aspirin Ec 81 Mg Tablet SIG: take one tablet daily
3 Triazolam 0.25 Mg Tablet SIG: Take 1 tab by mouth once daily
4 Nitrolingual 0.4 Mg Spray Mg/dose SIG: use as needed
5 Avodart 0.5 Mg Capsule (Other MD) SIG: Take 1 cap by mouth once daily

ALLERGIES / INTOLERANCES:
Calcium Channel Blockers, Crestor

SOCIAL HISTORY:
Marital Status: The patient is married.
Smoking/tobacco use: No history of smoking.
Alcohol: Non alcoholic beverage drinker.
Recreational drug use: He denies recreational drug use.
Diet: No diet restrictions.
Caffeine Intake: Drinks coffee occasionally.

FAMILY HISTORY:
Non-contributory.
REVIEW OF SYSTEMS:
Constitutional Symptoms: (-) fever, (-) chills, (-) night sweats, (-) fatigue, (-) weakness, (-) changes in appetite or weight.

Integumentary: (-) rash, (-) lumps, (-) itching, (-) dryness, (-) acne, (-) discoloration, (-) recurrent skin infections, (-) changes in hair, nails or moles.

Head: (-) headaches, (-) head injury or deformity, (-) visual changes, (-) eye pain, (-) double or blurred vision, (-) hearing changes, (-) tinnitus, (-) vertigo, (-) use of hearing aids, (-) frequent colds, (-) nasal allergies. Ears, Nose, Mouth, Throat: (-) hearing changes, (-) tinnitus, (-) vertigo, (-) dizziness, (-) earache, (-) ear infection, (-) ear discharge, (-) use of hearing aids.

Respiratory: (-) cough, (-) hemoptysis, (-) cyanosis, (-) wheezing, (-) nocturnal choking or gasping.

Cardiovascular: (-) chest pain, (-) edema, (-) high blood pressure, (-) irregular heartbeat, (-) orthopnea, (-) palpitations, (-) paroxysmal nocturnal dyspnea, (-) shortness of breath.

Gastrointestinal: (-) abdominal pain, (-) heartburn, (-) constipation, (-) diarrhea, (-) nausea, (-) vomiting, (-) hematochezia, (-) melena, (-) change in bowel habits.

Genitourinary: (-) dysuria, (-) frequency, (-) urgency, (-) hesitancy, (-) polyuria, (-) nocturia, (-) hematuria, (-) urinary incontinence, (-) flank pain, (-) change in urinary habits.

Musculoskeletal: (-) muscle pain, (-) joint pain, (-) bone pain.

Peripheral Vascular: (+) intermittent claudication.
Peripheral Vascular: (+) intermittent claudication.
Neurological: (-) numbness, (-) tingling, (-) tremors, (-) seizures, (-) vertigo, (-) memory loss, (-) any focal or diffuse neurological deficits.

Endocrine: (-) heat or cold intolerance, (-) excessive sweating, (-) excessive thirst, (-) excessive hunger, (-) excessive urination, (-) hirsutism, (-) change in ring or shoe size.

Hematologic/Lymphatic: (-) anemia, (-) easy bruising, (-) excessive bleeding, (-) history of blood transfusions.

PHYSICAL EXAM:
Vitals:
BP: 126/81(Left Arm)(Supine)
Pulse: 71(Left brachial)(Supine)(Regular)

Weight: 150 lbs
Height: 5′ 5″
BMI: 24.96
BSA: 1.76
BP: 139/70(Left Arm)(Supine)
Pulse: 60(Left brachial)(Supine)(Regular)

General Appearance: The patient is an extremely pleasant 89 year old male who looks younger than his stated age. is well developed and well nourished in no apparent distress. His body habitus is within normal limits, his mood is normal. The patient has gait abnormality and requires transportation.
HEENT: Normocephalic and atraumatic. Pupils are equally round and reactive to light and accommodation. Extraocular muscles are intact. Patient’s neck is supple with no jugular venous distention, left carotid bruit was heard and carotid pulses are +2/2. Normal carotid artery upstroke bilaterally. Palpation is not painful and no thyromegaly nor lymphadenopathy can be appreciated.
Respiratory: Clear to auscultation bilaterally without wheezes or rhonchi. No intercostal retractions or accessory muscle use were noted.
Cardiovascular: Regular heart rate and rhythm. Cardiac point of maximal impulse at left fifth intercostal space mid-clavicular line. Normal S1, S2 with physiologic splitting of S2. II/VI systolic murmur. No thrills, rubs, gallops, or clicks were heard.
Gastroenterology: Abdomen is soft non-tender and non-distended. Positive bowel sounds, no hepatomegaly or splenomegaly was noted. No bruits were heard.
Extremities: No cyanosis, or clubbing. Femoral and popliteal pulses 2/2 bilaterally. Right DP trace/2, left DP 0/2.
Musculoskeletal: Motor strength is appropriately intact throughout bilaterally.
Neurologic: Patient is alert and oriented x3 with deep tendon reflexes appropriately intact throughout bilaterally, non-focal.
Psychiatric: Patient is conscious, cooperative, and well-oriented to time, place, and person. There are no mood swings or psychotic features. Patient’s insight is good. Memory and judgement are intact.
Skin: No skin rash, subcutaneous nodules, lesions or ulcers observed.
DIAGNOSTIC DATA:

ELECTROCARDIOGRAM: Date performed: Apr 7, 2016.
Indication: Recurrent chest pain s/p PCI, Occasional shortness of breath.
Interpretation: Rate: 68 bpm; Rhythm: Normal sinus rhythm, Non-specific ST-T changes and intraventricular conduction delay; Axis: Left axis deviation; Left Ventricular Hypertrophy.
Conclusion: Abnormal ECG.

2D COLOR DOPPLER ECHOCARDIOGRAPHY:
Date: Mar 22, 2016 Indication: Recurrent shortness of breath, H/O severe CAD, H/O severe PVD S/P Bioprosthetic AVR, 2/6 systolic murmur, Abnormal EKG.

Findings:
Left atrium: Dimension: 4.1 cm. (Men: 3-4 cm/Women: 2.7-3.8 cm). It is moderately dilated.
Left ventricle:
-LVIDd = 3.8 cm (Men:4.2-5.9 cm/Women: 3.9-5.3cm).
-LVIDs = 3.2 cm (2.0-4.1 cm).
-IVS = 0.8 cm (0.6-1.1 cm).
-LVPWd = 0.8 cm (0.6-1.1 cm).
Wall kinesis: There is E-A flow reversal suggestive of diastolic dysfunction. Anterior wall akinesis, inferior and lateral wall severe hypokinesis.

Right atrium: Normal in size and shape and shows no signs of ASD, mass or thrombus.
Right ventricle: RVSP: 37 mmHg (15-25 mmHg). Increased right ventricular pressure.

Aortic valve: Peak Velocity = 2.4 m/sec (1.0 – 1.7 m/sec). Mild aortic valve stenosis.
Mitral valve: Moderate regurgitation.
Tricuspid valve: Moderate regurgitation.
Aorta: Ascending aorta: 3 cm. ( 2.1-3.4 cm).

Left ventricle ejection fraction: 25 %.

Pericardium: No effusion or calcification.

Recommendations: Repeat Cardiac Catheterization possible intervention.

TREADMILL STRESS TEST/W STRESS ECHOCARDIOGRAPHY.
Date: Aug 11, 2014. Indication: Occasional shortness of breath, Abnormal EKG, Pre-Op evaluation
Risk and benefits of exercise stress test including but not limited to myocardial infarction, vascular compromise and death were explained to Mr. GOLDBERG in detail. The patient asked appropriate questions. All questions were answered. The patient wished to proceed and gave his informed consent.

Protocol: Standard Bruce protocol.

Procedure:
STAGE I (Min 0 to 2:50): Min: 1 . MPH: 1.7. Grade: 10 %. MET: 1-5. BP: 140/86, Pulse: 82, O2 Sat: 100.

Results:
Maximal Predicted Heart Rate: 133 bpm.
Peak heart rate achieved: 92 bpm.
Maximal heart rate achieved: 69 % of predicted heart rate.
Average O2 saturation throughout the study: 100 %.
Total Minutes: 3.
Reason for stopping: Shortness of breath. bilateral calf pain 1 min into exercise.

Clinical response:
Peak exercise electrocardiogram revealed 1.0 mm ST depression in V4 to V6; resolved 1 min into recovery. Occasional ventricular bigeminy.

Stress echocardiography:
Revealed normal left ventricular function at rest with an adequate increase in left ventricular function in response to exercise.

Findings:
Left atrium: Dimension: 3.6 cm. (Men: 3-4 cm/Women: 2.7-3.8 cm).
Left ventricle:
-LVIDd = 3.3 cm (Men:4.2-5.9 cm/Women: 3.9-5.3cm).
-LVIDs = 2.7 cm (2.0-4.1 cm).
-IVS = 0.9 cm (0.6-1.1 cm).
-LVPWd = 0.9 cm (0.6-1.1 cm).
Wall kinesis: Distal anteroseptal + apical akinesis, small apical aneurysm.
Aorta: Ascending aorta: 3.3 cm. ( 2.1-3.4 cm).

Left ventricle ejection fraction: 40-45 %.

Summary: The patient exercised according to the BRUCE protocol for a total of 3 minutes, achieving a peak heart rate of 93 bpm, 69% of the maximum predicted heart rate. The electrocardiogram showed ST-T changes as mentioned above. Dysrrhythmias were seen as mentioned above.
Blood pressure response to exercise was normal at 140/86 mmHg.
Symptoms at peak exercise: shortness of breath, bilateral calf pain.
The study was inconclusive.

Conclusion:
Response to exercise: Stress testing performed today was inconclusive given that the target exercise time duration was not achieved and that the maximal target heart rate was not achieved.
Probability of obstructive coronary artery disease: Inconclusive.

Recommendations: Given stress test results and high pretest probability I recommend cardiac catheterization/Possible intervention.

CAROTID ARTERY DUPLEX SCAN:
Date of Study: Oct 12, 2015.
Indication: History of occasional dizziness, Left carotid bruit.

Measurements:
Left:
CCA distal peak velocity: 105 cm/sec.
CCA end diastolic velocity: 23 cm/sec.
ICA distal peak velocity: 87 cm/sec.
ICA end diastolic velocity: 30 cm/sec.
ECA distal peak velocity: 183 cm/sec.
ECA end diastolic velocity: 30 cm/sec.
Left vertebral artery showed antegrade flow.
ICA/CCA: 0.8.
Right:
CCA distal peak velocity: 90 cm/sec.
CCA end diastolic velocity: 20 cm/sec.
ICA distal peak velocity: 63 cm/sec.
ICA end diastolic velocity: 22 cm/sec.
ECA distal peak velocity: 85 cm/sec.
ECA end diastolic velocity: 14 cm/sec.
Right vertebral artery showed antegrade flow.
ICA/CCA: 0.7.

Impression/Comments:
Left:
Left bulb calcified plaque: 30%.
Right:
Right bulb calcified plaque: 30%.
Right ICA: plaque 20%.

Plan:
Non-obstructive disease.
Will intensify medical therapy.

LOWER EXTREMITIES VENOUS DOPPLER: Sep 22, 2014.
Indication: Leg pain, +1 Bilateral leg edema.
Impression: Normal venous flow with normal collapse with compression. Normal augmentation of venous flow with calf compression. No evidence of venous insufficiency with valsalva manuever or abdominal pressure. Normal lower extremities. The Doppler signals were phasic with good augmentation.
The images showed widely patent veins that were fully compressible.
No evidence of deep venous thrombosis or venous outflow obstruction of the lower extremities by duplex scanning.

LOWER EXTREMITIES ARTERIAL DUPLEX:
Date: Oct 5, 2012 Indication: Pain in Limb Peripheral vascular disease.

Measurements:
Artery:
Common Femoral:
Right: 1.21 m/s Waveform: Biphasic Plaque: less than 40%.
left: 1.5 m/s Waveform: Biphasic Plaque: less than 50%.
Profunda Femoris:
Right: 0.89 m/s Waveform: Biphasic Plaque: less than 20%.
left: 1 m/s Waveform: Biphasic Plaque: less than 20%.
Superficial Femoral:
Left: :
Proximal S.F.A.: : 0.6 m/s Waveform: Biphasic Plaque: less than 10%.
MID S.F.A: : 0.46 m/s Waveform: Biphasic Plaque: less than 10%.
Distal S.F.A.: : 0.81 m/s Waveform: Biphasic Plaque: less than 10%.
Right: :
Proximal S.F.A.: : 0.53 m/s Waveform: Biphasic Plaque: less than 20%.
MID S.F.A: : 0.87 m/s Waveform: Biphasic Plaque: less than 20%.
Distal S.F.A.: : 1.42 m/s Waveform: Biphasic Plaque: 30%.
Popliteal:
Right: 0.98 m/s Waveform: Biphasic Plaque: less than 40%.
left: 0.53 m/s Waveform: Biphasic Plaque: less than 30%.

Impression:
Normal study. Non-Obstructive disease.

Recommendations: Intensify medical therapy.

RENAL ARTERY-AORTA DUPLEX SCAN (Partial Study – pt declines study on lt kidney): Aug 25, 2014.
Indication: Hypertension (401.1) History of severe CAD.

Measurements:
Right Renal Peak Systolic Velocity:
Proximal: 0.39 m/s [<1.0].
Mid: 0.68 m/s [<1.0].
Distal: 0.36 m/s [<1.0].
Renal/Aortic Ratio: 0.5. [<3.5].

Aorta:
Proximal Aortic Diameter: 1.6 cm.
Mid Aortic Diameter: 1.3 cm.
Distal Aortic Diameter: 1 cm.
Aortic Peak Systolic Velocity: 1.33 m/s.

Kidney:

Right:
kidney length: 8.9 cm [8.5-15.0 cm].
Kidney Width: 4.2 cm. ( 4.5-5.0 cm].
Kidney Depth (trans): 3.7 cm. [4.5-5.0].
Cortical Thickness: 1.4 cm. [1.1 cm].
Parenchymal Flow /Waveform:
Upper Early Systolic Peak Present.
Mid Early Systolic Peak Present.
Lower Early Systolic Peak Present.
Resistive Index: 0.76 [<0.75]
(PSV-EDV/PSV).

Technical impression:
Within normal limits.

ABDOMINAL AORTA DUPLEX SCAN:
Date: Jun 23, 2014 Indication: Indication: Hypertension (401.1) Peripheral Vascular disease.

Aorta:
Proximal Aortic Diameter: 1.7 cm.
Proximal Aortic Peak Systolic Velocity: 0.96 m/s.
Mid Aortic Diameter: 1.3 cm.
Mid Aortic Peak Systolic Velocity: 2.48 m/s.
Distal Aortic Diameter: 0.9 cm.
Distal Aortic Peak Systolic Velocity: 0.88 m/s.

Technical impression: Abnormal study. Mild plaque. Moderately elevated PSV seen in the mid abdominal aorta.
Follow up with Dr. Nassoura is recommended.

Cardiac Catheterization: Cardiac cath 09/19/12
-Left main had approximately 95% disease in its distal section at the area of the trifurcation of the left anterior descending, ramus and circumflex arteries.
– The left anterior descending was 100% occluded with evidence of a septal branch as the only branch
off the LAD. The ramus branch was a small vessel, less than 1.5 cm.
-The circumflex artery had evidence of reciprocating flow.
-Right coronary artery was severely diseased at its proximal section approximately 90% to 95%. It fed only the right side of the heart and therefore was nondominant.
– Left anterior internal mammary artery was widely patent and supplied the left anterior descending. In addition, there was a sequential LIMA to the first and second obtuse marginal branches. There was no other evidence of disease in the obtuse marginal branches.
-The distal left anterior descending had moderate disease, approximately 60% after the anastomosis of the LIMA.
– LVEDP measured 20 mmHg pullback across the aortic valve showed mild 12 mmHg gradient.
IMPRESSION:
1. Status post cardiac catheterization. No complications. I tried to minimize the contrast dye given the patient’s history of renal insufficiency. Recent echocardiogram showed ejection fraction of approximately 40% with distal anterior septal akinesis.
2. Severe coronary artery disease as outlined above.
3. Coronary artery bypass grafting with LIMA to the LAD and sequential to the 1st and 2nd obtuse marginal vessels.
4. Status post bioprosthetic aortic valve with mild gradient.
5. Significantly increased left ventricular end-diastolic pressure. Shortness of breath, possibly because of increased LVEDP. The patient will be managed as an outpatient and medications will be adjusted as an outpatient. I had a long discussion with the patient and his son regarding my findings. The patient tolerated procedure well, and was sent to the recovery room in stable condition.

Cardiac cath 08/20/14.
The arteries were heavily calcified and the left main was occluded in its proximal to mid section.
-The right coronary artery was nondominant.
– Left subclavian angiography revealed no significant left subclavian stenosis.
– Left internal mammary artery was not obstructive. The left anterior
descending artery had mild to moderate disease in its mid distal section
up to 60 percent. The LIMA was sequentially grafted to the LAD and 1st
and 2nd obtuse marginal. The 1st and 2nd obtuse marginal, were small
and there was no significant disease.
-The native circumflex artery was filling retrogradely and there was moderate to severe disease in the circumflex vessel.
– There was mild disease in the right common femoral artery.
POSTOPERATIVE DIAGNOSIS: Severe coronary artery disease as outlined
above and status post coronary artery bypass grafting.

Other: Exercise Myocardial Perfusion SPECT 10/17/08
-Likelihood of jeopardized myocardium: high (>90%)
-Large sized moderate infarction involving the distal anterior and mid to septal walls extending to the apex with a small amount of mild peri-infarction ischemia involving the mid anterior wall, most likely in the distribution of the LAD.
-EF 49%.
Myocardial SPECT 08/27/12
-No ischemic changes.

PET SCAN performed on 02/13/2014 showed:
-Likelihood of jeopardized myocardium: very high (>98 %)
-A small or medium sized nonreversible defect in LAD involving the septal and apical wall, with an adjacent large reversible defect in the anterior and septal walls.

PNEUMONIA VACCINATION: Nov 26, 2012.

————————————————————————————————————————————————————
DIAGNOSIS/ASSESSMENT:

COMPLEX, HIGH RISK PATIENT.

SEVERE CORONARY ARTERY DISEASE.
Coronary artery bypass grafting (2001) with LIMA to the LAD and sequential to the 1st and 2nd obtuse marginal vessels. S/p LVAD – IMPLELLA INSERTION, PTCA/DE STENT (4.0x18mm Xience Alpine) SFV GRAFT (TO OM) on 04/06/16. The patient was advised of the importance of following a healthy diet, weight loss and daily aerobic exercise. He was instructed to contact me if he has recurrent chest pain or he develops any other symptoms or decreased exercise tolerance.

H/O DYSPNEA.
ISCHEMIC CARDIOMYOPATHY.
Severe coronary artery per cardiac cath as outline above. Severely diminished left ventricle ejection fraction. EF at 25 %. S/p LVAD – IMPLELLA INSERTION.

PERIPHERAL VASCULAR DISEASE.
INTERMITTENT CLAUDICATION.
The patient has a history of severe peripheral vascular disease. Patient underwent lower extremity angiography and unsuccessful percutaneous intervention on 09/26/14. The patient continues to have symptoms. Long discussion with the patient about the importance of healthy lifestyle including healthy low fat diet, daily aerobic exercise program, and maintaining optimal lipid profile. Defer management Dr. Nassoura.

AORTIC VALVE DISORDER.
H/o severe aortic stenosis, s/p Aortic valve replacement Jan 2001. Mild aortic sclerosis, mild prosthetic aortic stenosis, and peak AV Velocity = 2.4 m/sec per echocardiography. Will follow with serial echocardiography.

HYPERTENSIVE HEART DISEASE.
No evidence of renal artery stenosis/abdominal aorta aneurysm/LVH on diagnostic studies. Patient to continue to monitor his blood pressure twice daily and provide me the records. Low salt diet advised.

HYPERLIPIDEMIA.
Low fat, healthy diet and daily aerobic exercise advised.

RENAL INSUFFICIENCY.
BUN 48 mg/dL, Cr. 1.73 mg/dL and GFR 34 ml/min per labs on 06/28/16. Subsequently Benazepril-Hct was d/c. Repeat labs today.

H/O HYPERKALEMIA.
Serum Potassium normalized, 5.5 mmol/l per labs on 06/28/16. Avoid potassium rich food. Labs today.

OTHER.
– Renal cysts. (2) Simple cysts seen in the left kidney measuring 1.5 cm x 1.4 cm x 1.5 cm and 1.4 cm x 1.3 cm x 1.4 cm. Stable. Recommend follow-up with Dr. Navon.
– The patient has gait abnormality and needs transportation.

DISCUSSION:

PLAN:
Medication changes:
Discontinue Edarbi given renal insufficiency. Trial of Hydralazine 50 mg PO BID, hold if systolic bp < 110 mm Hg and Norvasc 5 mg PO QD.

Diet: Patient advised to follow a healthy low fat, salt and carbohydrate diet.

Exercise recommendations: Regular exercise is strongly recommended.

Hypertension Instructions: The patient was instructed to monitor their blood pressure twice daily and provide me with the records.

Preventive Medicine: It is important that the patient follow up with their primary physician for preventative medicine follow ups including yearly prostate exam and annual physical exam.

Follow Up: The patient was advised to return to the office for follow up in 3 weeks and to return earlier if he has any medical problems.

Emergency recommendations: The patient was advised to call 911 or go to the emergency room if the patient’s condition worsens or does not improve.

——————————————————————————————————————————————————-

Check in time: 08:33 AM Check out time: 09:21 AM

Electronically signed: 07/06/2016 09:47 AM BENZUR, URI

G8427 Med.with dosage and verification documented; 1036F CURRENT TOBACCO NON-USER CAD CAP COPD PV DM; 99213 Office/outpatient visit, est, mod; G8419 BMI abnormal. No followup plan documented

Uri M. Ben-Zur, M.D., F.A.C.C.
Interventional Cardiology / Invasive Electrophysiology

18200 Ventura Blvd
Tarzana, CA 91356
Phone (818) 986-0911 Fax (818) 986-9301

Date of visit: 07/05/2016
Reason for Visit:
Requesting Physician:
on the date stated above. I have reviewed the past medical history, symptoms and current therapy. In addition, I have examined the patient and based on my findings have provided my overall impression, outlining my treatment and plans in the summary below.

CHIEF COMPLAINT /HISTORY OF PRESENT ILLNESS:

is an extremely pleasant 64 year old male with a past medical history of severe coronary artery disease, hypertension, hyperlipidemia, diabetes mellitus type-2. He is accompanied today by his wife, Bella.

The patient complains bilateral lower extremity numbness.

The patient complains of non-exertional mid-sternal chest pressure. This symptom has existed for about 2 weeks, and it has not changed in severity, frequency, or quality. It is mild in severity. It lasts for a few minutes and resolves spontaneously. No associated symptoms or modifying factors noted.

The patient denies shortness of breath, palpitations, dizziness, syncope.

The patient’s blood pressure average 130-140 mmHg according to his home monitor. His blood sugar levels range from 140 to 155 mg/dL according to his home monitor. The patient does not follow an exercise program. He is improving his dietary habits.

At the time of his last visit, no medication changes were made. The patient’s wife states that he is not taking Invokana, because she read about it and was worried about potential side effects.
PAST MEDICAL HISTORY:
Cardiovascular:
Coronary Artery Disease.
Hyperlipidemia.
Hypertension, benign essential.
Respiratory:
Probable Chronic Obstructive Pulmonary Disease.
Musculoskeletal:
Chronic Back Pain.
Neurology:
Neuropathy.
Endocrine:
Diabetes mellitus.
SURGICAL HISTORY:
Cardiac cath 2004
Lap band 2004
Cardiac cath 10/08/14. Status post percutaneous coronary intervention and stent placement x 3 to mid circumflex, mid diagonal, ostial diagonal vessels.
Cardiac cath 12/17/14.

CURRENT MEDICATIONS:
1 Tums Tablet Chewable 200 Mg Calcium (500 Mg) SIG: 2 Tabs PO PRN dyspepsia
2 Aspirin 81 Mg Chewable Tablet SIG: take one tablet daily
3 Benazepril Hcl 40 Mg Tablet SIG: one PO QD
4 Januvia 100 Mg Tablet SIG: Take one tablet PO daily
5 Livalo 2 Mg Tablet SIG: 1 Tablet PO QD
6 Metformin Hcl 1,000 Mg Tablet SIG: one PO BID
7 Metoprolol Succ Er 50 Mg Tab SIG: One tab PO BID.
8 Nexium Dr 40 Mg Capsule SIG: one cap daily
9 Vitamin D 2,000 Unit Softgel SIG: 1 Tablet PO Once weekly
10 Plavix 75 Mg Tablet SIG: one tablet PO daily
11 Voltaren 1% Gel SIG: use BID
12 Isosorbide Dn 30 Mg Tablet SIG: One tab PO BID
13 Glipizide 5 Mg Tablet (Other MD) SIG: Take 1 by mouth twice daily, hold if FBS < 120 mg/dL

ALLERGIES / INTOLERANCES:
SOCIAL HISTORY:
Marital Status: The patient is married.
Smoking/tobacco use: Discontinued 2004. 42 pack years.
Alcohol: The patient occasionally drinks alcoholic beverages. He has one shot of vodka 2-3 times a year.
Recreational drug use: He denies recreational drug use.
Occupation: The patient is disabled.

FAMILY HISTORY:

REVIEW OF SYSTEMS:
Constitutional Symptoms: (-) fever, (-) chills, (-) night sweats, (-) fatigue, (-) weakness, (-) changes in appetite or weight.

Integumentary: (-) rash, (-) lumps, (-) itching, (-) dryness, (-) acne, (-) discoloration, (-) recurrent skin infections, (-) changes in hair, nails or moles.

Respiratory: (-) cough, (-) hemoptysis, (-) cyanosis, (-) wheezing, (-) nocturnal choking or gasping.

Cardiovascular: (+) chest pain exertional non-exertional, (-) dizziness, (-) dyspnea with exertion, (-) edema, (-) high blood pressure, (-) irregular heartbeat, (-) palpitations, (-) Syncope.
Cardiovascular: (+) chest pain exertional non-exertional.
Gastrointestinal: (-) abdominal pain, (-) heartburn, (-) constipation, (-) diarrhea, (-) nausea, (-) vomiting, (-) hematochezia, (-) melena, (-) change in bowel habits.

Genitourinary: (-) dysuria, (-) frequency, (-) urgency, (-) hesitancy, (-) polyuria, (-) nocturia, (-) hematuria, (-) urinary incontinence, (-) flank pain, (-) change in urinary habits.

Musculoskeletal: (-) muscle pain, (-) joint pain, (-) bone pain.

Peripheral Vascular: (-) intermittent claudication, (-) cramps, (-) varicose veins, (-) thrombophlebitis.

Neurological: (+) BL LE numbness.
Neurological: (+) BL LE numbness.
Endocrine: (-) heat or cold intolerance, (-) excessive sweating, (-) excessive thirst, (-) excessive hunger, (-) excessive urination, (-) hirsutism, (-) change in ring or shoe size.

Hematologic/Lymphatic: (-) anemia, (-) easy bruising, (-) excessive bleeding, (-) history of blood transfusions.

PHYSICAL EXAM:
Vitals:
BP: 118/63(Left Arm)(Standing)
Pulse: 68(Left brachial)(Standing)

Weight: 205 lbs
Height: 5′ 7″
BMI: 32.10
BSA: 2.09
BP: 117/64(Left Arm)(Supine)
Pulse: 63(Left brachial)(Supine)(Regular)

General Appearance: The patient is an extremely pleasant 64 year old male who looks younger than his stated age. is well developed and well nourished in no apparent distress. His body habitus is obese. His mood is normal.
HEENT: Normocephalic and atraumatic. Pupils are equally round and reactive to light and accommodation. Extraocular muscles are intact. Patient’s neck is supple with no jugular venous distention, no carotid bruit was heard and carotid pulses are +2/2. Normal carotid artery upstroke bilaterally. Palpation is not painful and no thyromegaly nor lymphadenopathy can be appreciated.
Respiratory: Clear to auscultation bilaterally without wheezes or rhonchi. No intercostal retractions or accessory muscle use were noted.
Cardiovascular: Regular heart rate and rhythm. Cardiac point of maximal impulse at left fifth intercostal space mid-clavicular line. Normal S1, S2 with physiologic splitting of S2. II/VI systolic murmur. No thrills, rubs, gallops, or clicks were heard.
Gastroenterology: Abdomen is soft non-tender and non-distended. Positive bowel sounds, no hepatomegaly or splenomegaly was noted. No bruits were heard.
Extremities: Pulses were 2+ throughout bilaterally. No cyanosis, edema or clubbing.
Musculoskeletal: Motor strength is appropriately intact throughout bilaterally.
Neurologic: Patient is alert and oriented x3 with deep tendon reflexes appropriately intact throughout bilaterally, non-focal.
Psychiatric: Patient is conscious, cooperative, and well-oriented to time, place, and person. There are no mood swings or psychotic features. Patient’s insight is good. Memory and judgement are intact.
Skin: No skin rash, subcutaneous nodules, lesions or ulcers observed.
DIAGNOSTIC DATA:

ELECTROCARDIOGRAM: Date performed: Jul 5, 2016.
Indication: atypical chest pain, History of severe CAD S/P PCI, Occasional shortness of breath.
Interpretation: Rate: 60 bpm; Rhythm: Normal sinus rhythm; S/P Inferior wall myocardial infarction – age undetermined.
Conclusion: Abnormal ECG.

2D COLOR DOPPLER ECHOCARDIOGRAPHY:
Date: Jul 5, 2016 Indication: Occasional shortness of breath, history of severe CAD S/P PCI and history of recurrent angina.
Technically difficult study given morbidly obese patient.

Findings:
Left atrium: Dimension: 3.4 cm. (Men: 3-4 cm/Women: 2.7-3.8 cm). Normal in size.
Left ventricle:
-LVIDd = 3.9 cm (Men:4.2-5.9 cm/Women: 3.9-5.3cm).
-LVIDs = 2 cm (2.0-4.1 cm).
-IVS = 0.9 cm (0.6-1.1 cm).
-LVPWd = 1 cm (0.6-1.1 cm).

Right atrium: Normal in size and shape and shows no signs of ASD, mass or thrombus.
Right ventricle: RVSP: 30 mmHg (15-25 mmHg). Normal in size and shape and shows no evidence of VSD or mass.

Aortic valve: Peak Velocity = 1.9 m/sec (1.0 – 1.7 m/sec). No regurgitation. No sclerosis. No stenosis. Normal trileaflet aortic valve.
Mitral valve: Mild regurgitation. No sclerosis. No stenosis. No valve prolapse.
Tricuspid valve: Mild regurgitation. No sclerosis. No stenosis.
Pulmonic valve: Normal pulmonic valve.
Aorta: Ascending aorta: 3 cm. ( 2.1-3.4 cm), No evidence of aortic aneurysm.

Left ventricle ejection fraction: 60 %.

Pericardium: No effusion or calcification.
Venous: Inferior vena cava: Normal diameter with normal respiratory variation.

TREADMILL STRESS TEST/W STRESS ECHOCARDIOGRAPHY.
Date: Jun 17, 2016. Indication: New onset chest pain, Abnormal EKG, History of severe CAD S/P PCI
Risk and benefits of exercise stress test including but not limited to myocardial infarction, vascular compromise and death were explained to Mr. PINCHEVSKIY in detail. The patient asked appropriate questions. All questions were answered. The patient wished to proceed and gave his informed consent.

Protocol: Standard Bruce protocol.

Procedure:
STAGE I (Min 0 to 2:50): Min: 2 . MPH: 1.7. Grade: 10 %. MET: 1-5. BP: 162/94, Pulse: 97, O2 Sat: 98 (Room air).

Results:
Maximal Predicted Heart Rate: 156 bpm.
Peak heart rate achieved: 100 bpm.
Maximal heart rate achieved: 64 % of predicted heart rate.
Average O2 saturation throughout the study: 98 %.
Total Minutes: 3.3.
Reason for stopping: Generalized fatigue.

Clinical response:
Peak exercise electrocardiogram revealed no significant ischemic changes and no significant arrhythmias.

Stress echocardiography:

Left ventricle ejection fraction: 60 %.

Summary: The patient exercised according to the BRUCE protocol for a total of 3.3 minutes, achieving a peak heart rate of 100 bpm, 64% of the maximum predicted heart rate. Electrocardiogram showed no significant ST-T changes. Atrial premature contractions/ventricular premature contractions/dysrhythmias were not seen.
Blood pressure response to exercise was normal at 162/94 mmHg.
Symptoms at peak exercise: generalized fatigue.
The study was inconclusive.

Conclusion:
Response to exercise: Stress testing performed today was inconclusive given that the target exercise time duration was not achieved and the maximal target heart rate was not achieved.
There is no evidence of inducible ischemia at the level of exercise achieved.
No evidence of stress induced arrhythmias at the level of exercise achieved.
The patient had an inadequate exercise capacity.
Probability of obstructive coronary artery disease: Inconclusive.

Recommendations:
A Thallium and probable cardiac cath.

CAROTID ARTERY DUPLEX SCAN:
Date of Study: Oct 14, 2014.
Indication: History of carotid artery disease and patient requested.

Measurements:
Left:
CCA distal peak velocity: 65 cm/sec.
CCA end diastolic velocity: 19 cm/sec.
ICA distal peak velocity: 86 cm/sec.
ICA end diastolic velocity: 40 cm/sec.
ECA distal peak velocity: 145 cm/sec.
ECA end diastolic velocity: 14 cm/sec.
Left vertebral artery showed antegrade flow.
ICA/CCA: 1.3.
Right:
CCA distal peak velocity: 70 cm/sec.
CCA end diastolic velocity: 14 cm/sec.
ICA distal peak velocity: 75 cm/sec.
ICA end diastolic velocity: 26 cm/sec.
ECA distal peak velocity: 130 cm/sec.
ECA end diastolic velocity: 12 cm/sec.
Right vertebral artery showed antegrade flow.
ICA/CCA: 1.1.

Impression/Comments:

Findings: Bilateral mild plaque.

Plan:
Non-obstructive disease.
Will intensify medical therapy.

LOWER EXTREMITIES VENOUS DOPPLER: Mar 17, 2015.
Indication: Occasional shortness of breath, +1 Bilateral leg edema.
Impression: Normal venous flow with normal collapse with compression. Normal augmentation of venous flow with calf compression. No evidence of venous insufficiency with valsalva manuever or abdominal pressure. Normal lower extremities. The Doppler signals were phasic with good augmentation.
The images showed widely patent veins that were fully compressible.
No evidence of deep venous thrombosis or venous outflow obstruction of the lower extremities by duplex scanning.

RENAL ARTERY-AORTA DUPLEX SCAN: Dec 15, 2014.
Indication: Hypertension (401.1) Severe CAD.

Measurements:
Left Renal Peak Systolic Velocity:
Proximal: 0.92 m/s [<1.0].
Mid: 0.58 m/s [<1.0].
Distal: 0.49 m/s [<1.0].
Renal/Aortic Ratio: 0.8. [<3.5].
Right Renal Peak Systolic Velocity:
Proximal: 0.53 m/s [<1.0].
Mid: 0.77 m/s [<1.0].
Distal: 0.49 m/s [<1.0].
Renal/Aortic Ratio: 0.7. [<3.5].

Aorta:
Proximal Aortic Diameter: 2.3 cm.
Mid Aortic Diameter: 1.6 cm.
Distal Aortic Diameter: 1.3 cm.
Aortic Peak Systolic Velocity: 1.16 m/s.

Kidney:
Left:
kidney length: 10.6 cm [8.5-15.0 cm].
Kidney Width: 5 cm. ( 4.5-5.0 cm].
Kidney Depth (trans): 4.9 cm. [4.5-5.0].
Cortical Thickness: 1.6 cm. [1.1 cm].
Parenchymal Flow /Waveform:
Upper Early Systolic Peak Present.
Mid Early Systolic Peak Present.
Lower Early Systolic Peak Present.
Resistive Index: 0.71 [<0.75] (PSV-EDV/PSV).

Right:
kidney length: 11.5 cm [8.5-15.0 cm].
Kidney Width: 5.1 cm. ( 4.5-5.0 cm].
Kidney Depth (trans): 4.9 cm. [4.5-5.0].
Cortical Thickness: 1.6 cm. [1.1 cm].
Parenchymal Flow /Waveform:
Upper Early Systolic Peak Present.
Mid Early Systolic Peak Present.
Lower Early Systolic Peak Present.
Resistive Index: 0.67 [<0.75]
(PSV-EDV/PSV).

Technical impression:
Within normal limits.

ABDOMINAL AORTA DUPLEX SCAN:
Date: Dec 1, 2014 Indication: Indication: Hypertension (401.1) plaque.

Aorta:
Proximal Aortic Diameter: 2.5 cm.
Proximal Aortic Peak Systolic Velocity: 0.86 m/s.
Mid Aortic Diameter: 1.8 cm.
Mid Aortic Peak Systolic Velocity: 1.06 m/s.
Distal Aortic Diameter: 1.4 cm.
Distal Aortic Peak Systolic Velocity: 0.93 m/s.

Technical impression:
mild plaque.

Cardiac Catheterization: 01/15/04
RCA: Dominant with diffuse 10% plaquing throughout the course. A small caliber Posterolateral branch with 90% focal stenosis.
– Left main: Luminal irregularities.
– LAD: moderate caliber vessel with 70% stenosis at the takeoff of a second diagonal vessel. Distal LAD: Markedly narrowed with diffuse disease encompassing the entire apical portion. A moderate caliber first diagonal vessel: 60% ostial stenosis.
– CIRC: non-dominant vessel with no proximal disease. Distal circ: diffuse 80% disease and a narrow caliber vessel. Second diagonal: moderate caliber vessel with diffuse disease.
– LVEDP 20 mmHg.
– The patient has mild anterior wall hypokinesis with a preserved EF of 60%. No MR.
Impression: 70% mid LAD stenosis and high grade diffuse disease in a narrow caliber apical portion of the LAD as well as distal circ.
– 3.0 x 23 mm Cypher stent placed in LAD.

Cardiac Catheterization and Angioplasty: 10/08/14
Left main was nonobstructed.
Left anterior descending had approximately 40 percent disease just after the takeoff of the diagonal vessel and just after that takeoff of the diagonal vessel there was evidence of a stent, which appeared to have minimal in-stent restenosis, approximately 10-20 percent. First diagonal vessel had approximately 90 percent ostial disease with approximately 90 percent mid vessel disease associated with TIMI 2 flow. The very distal portion of the LAD, the vessel was less than 1.5 mm in diameter, had approximately 90-95 percent disease.
The circumflex artery had significant disease in its distal section approximately 90-95 percent disease. The obtuse marginal vessel had significant disease at its ostium of approximately 90 percent with TIMI 3 flow. The distal circumflex was a very small vessel.
The right coronary artery had mild disease in its proximal and mid section approximately 20-30 percent disease. The distal PLV branch had mid PLV occlusion 100 percent with collateral filling of the distal portion of the posterior left ventricular branch.
LVEDP measured approximately 18 mmHg. LV gram showed normal overall LV function with an ejection fraction of approximately 55 percent. There was no evidence of significant mitral regurgitation.
– A 2.25 x 12 mm Xience Xpedition drug-eluting stent was placed in the mid section of the diagonal vessel, a 2.25 x 15 mm Xience Xpedition drug-eluting stent was placed in the mid vessel disease.
– Proximal portion of the diagonal vessel: A 2.25 x 24 mm Promus Premier drug-eluting stent was placed in the mid section of the diagonal vessel.
-Ostial portion of the diagonal vessel: A 2.75 x 6 mm Trek balloon was placed in the ostium and dilated up to 8 atmospheres of pressure. It was hard to position the balloon and it kept moving either proximally or distally. A 2.5 x 6 mm AngioSculpt cutting balloon was then placed in the ostium of the diagonal vessel and dilated up to 8 atmospheres of pressure. Post dilatation of the second 190 cm balance middle weight wire was placed in the diagonal vessel and a monorail 3.0 x 8 mm Promus Premier drug-eluting stent was placed and position was carefully manipulated to the ostium of the diagonal vessel. It was dilated up to 12 atmospheres of pressure. Post dilatation the stent appeared to move backward mildly into the LAD proper. A 3.25 mm noncompliant Trek balloon catheter was then placed in the mid portion of the proximal ostial diagonal stent and dilated up to 12 atmospheres of pressure. Then a 190 cm x 0.014 BMW wire was then placed across the LAD lesion. The LAD was dilated in the area of the diagonal stent portion that moved back into the LAD. The stent was dilated with a 3.5 x 8 mm Trek balloon catheter, which was dilated up to 6 atmospheres of pressure. Post dilatation the wires were removed.
Angiography revealed normal to good stent apposition and no evidence of dissection or thrombus formation.
The patient tolerated the procedure well.

Other: Cardiac cath 12/17/14.
– Left main was not obstructed.
– Left anterior descending had approximately 20 percent disease in its midsection.
– Diagonal vessel had approximately 20 percent disease in its ostial section at the area of the previously placed stent. The stent appeared to be in the mid portion of the LAD and ostial portion of the diagonal vessel. The mid LAD had a stent in it.
– The circumflex artery had a previously placed stent, which was with 0 percent residual stenosis, TIMI-III flow. The distal circumflex artery was severely diseased and nearly occluded. It was a very small vessel.
– The right coronary artery had mild disease throughout with approximately 20 percent disease in its proximal, mid and distal sections. The distal PLV was a small vessel and was occluded. The decision was then made to perform FFR measurement of the diagonal and LAD given that the patient was symptomatic with shortness of breath and chest pain. FFR measured at 0.85. Therefore, the LAD is not obstructed.
– The diagonal vessel. FFR was measured. it was 0.92. Therefore, the diagonal and LAD vessels are nonobstructive by both angiography and FFR measurements.

————————————————————————————————————————————————————
DIAGNOSIS/ASSESSMENT:

RECURRENT CHEST PAIN.
SEVERE CORONARY ARTERY DISEASE.
The patient previously underwent PCI/stent placement x3, (mid circumflex, mid diagonal, ostial diagonal) on 10/08/14. Cardiac catheterization on 12/17/14 showed non obstructive coronary arteries. I had a long discussion with the patient and his wife regarding diagnostic and therapeutic options available to him. Recommend cardiac cath. He declined. Continue Aspirin, Plavix and Livalo. The patient was instructed NOT TO DISCONTINUE PLAVIX OR ASPIRIN WITHOUT MY WRITTEN APPROVAL. He was advised of the importance of cardiac risk factor modification, including optimal blood pressure, blood sugar, lipid profile, a healthy diet, weight loss and daily aerobic exercise. He is to proceed immediately to the nearest ER if his condition worsens.

HYPERTENSION.
Blood pressure readings within the normal range per the patient’s home monitor. No evidence of left ventricular hypertrophy per echocardiography. No evidence of renal artery stenosis or abdominal aortic aneurysm per Duplex scan. Patient to continue to monitor his blood pressure twice daily, and provide me with the records. Continue current medications for now. Low salt, healthy diet advised.

DYSLIPIDEMIA.
TG 238, LDL 106 mg/dL and HDL 38 mg/dL on 06/17/16. Continue Livalo. Lifestyle modifications including healthy diet advised.

DIABETES MELLITUS TYPE II.
Hb A1c 7.8% on 6/17/16. The patient is currently on Metformin, Januvia, and Glipizide. The patient is non-compliant and self adjusts medications. He was counseled on the importance of checking blood sugars regularly, adhering to medication regimen, following a low carbohydrate, healthy diet, and a daily exercise routine.

OTHER:
– Peripheral Neuropathy. Defer to his neurologist.
– Anemia. Recommend evaluation by Dr. Jacobs of gastroenterology and Dr. Lashkari of hematology.
– GERD. Recommend that the patient avoid eating for a few hours prior to going to bed, and sleep with the head of his bed elevated at a 45 degree angle. Recommend follow up with a gastroenterologist.

DISCUSSION:

PLAN:
Medication changes: No.

Procedures performed today: EKG, Complete Echocardiogram.

Diet: Patient advised to follow a healthy low fat, salt and carbohydrate diet.

Exercise recommendations: Regular exercise is strongly recommended.

Hypertension Instructions: The patient was instructed to monitor their blood pressure twice daily and provide me with the records.

Anxiety recommendations: The patient was advised to practice stress reduction techniques, including but not limited to meditation, deep breathing, yoga and exercise as tolerated.

Preventive Medicine: It is important that the patient follow up with their primary physician for preventative medicine follow ups including yearly prostate exam and annual physical exam.

Follow Up: The patient was advised to return to the office for follow up in 2 weeks or earlier if he has any medical problems.

Emergency recommendations: The patient was advised to call 911 or go to the emergency room if the patient’s condition worsens or does not improve.

——————————————————————————————————————————————————-

Check in time: 08:37 AM Check out time: 10:03 AM

Electronically signed:

93000 Electrocardiogram, complete (ECG); 93306 echo 2Dw/doppler echo/color flow doppler

Uri M. Ben-Zur, M.D., F.A.C.C.
Interventional Cardiology / Invasive Electrophysiology

18200 Ventura Blvd
Tarzana, CA 91356
Phone (818) 986-0911 Fax (818) 986-9301
Date of visit: 07/05/2016
Reason for Visit:
Requesting Physician:
I had the opportunity to evaluate M on the date stated above. I have reviewed the past medical history, symptoms and current therapy. In addition, I have examined the patient and based on my findings have provided my overall impression, outlining my treatment and plans in the summary below.

CHIEF COMPLAINT /HISTORY OF PRESENT ILLNESS:

Mis an extremely pleasant 66 year old female who has a past medical history of hypertension, hyperlipidemia and diabetes mellitus type II.

The patient is being seen frequently given fluctuating blood pressures and multiple medication adjustments.

The patient tells me she self discontinued Benazepril due to coughing. She has also self discontinued Metoprolol, Diovan, Clonidine. She has also self adjusted Bystolic to BID. The patient has also increased her Glucotrol to 10 mg BID.

The patient denies chest pain, shortness of breath, palpitations, dizziness, syncope.

Her systolic blood pressure readings have been elevated according to her home monitor, Her blood sugar levels average 170 mg/dL per the patient’s home monitor. Ms. PINCHEVSKIY is following an exercise program. She follows a healthy diet.

Overall,states that she is stable.
PAST MEDICAL HISTORY:
Cardiovascular:
Hyperlipidemia.
Hypertension, benign essential.
Gastroenterology:
Gastroesophageal Reflux.
Psychiatry:
Anxiety.
Allergy/Immunology:
Allergies: seasonal.
SURGICAL HISTORY:
No prior surgeries.

CURRENT MEDICATIONS:
1 Nexium Dr 40 Mg Capsule SIG: take one daily
2 Pepcid 20 Mg Tablet SIG: one tab PO QD
3 Calcium 600 Mg Tablet Mg (1,500 Mg) SIG: Take 1 tablet PO QD
4 Vitamin D 1,000 Units Softgel SIG: Take 1 tablet PO QD
5 Crestor 20 Mg Tablet SIG: PO QD
6 Metformin Hcl 1,000 Mg Tablet SIG: one tab PO TID
7 Paxil 20 Mg Tablet SIG: take one daily
8 Hydroxyzine Hcl 50 Mg Tablet SIG: (Atarax)
9 Aspirin 81 Mg Chewable Tablet SIG: take one daily
10 Bystolic 5 Mg Tablet SIG: Take one tablet PO BID, hold if sBP is less than 110 mmHg or pulse rate less than 45 bpm
11 Furosemide 20 Mg Tablet (Other MD) SIG: take 1/2 tab PO QD PRN leg edema

ALLERGIES / INTOLERANCES:
Biguanides, benazepril

SOCIAL HISTORY:
Marital Status: The patient is married, with 2 healthy children.
Smoking/tobacco use: No history of smoking.
Alcohol: Non alcoholic beverage drinker.
Recreational drug use: She denies recreational drug use.
Caffeine Intake: 1 cup of coffee/day.
Stress Level: Moderate.
Occupation: Caregiver.

FAMILY HISTORY:
Father is deceased. He died at the age of 56. Sudden death.
Mother is alive. H/o coronary artery disease, s/p myocardial infarction at 87. She has hypertension.
One brother, alive and healthy.
REVIEW OF SYSTEMS:
Constitutional Symptoms: (-) fever, (-) chills, (-) night sweats, (-) fatigue, (-) weakness, (-) changes in appetite or weight.

Integumentary: (-) rash, (-) lumps, (-) itching, (-) dryness, (-) acne, (-) discoloration, (-) recurrent skin infections, (-) changes in hair, nails or moles.

Head: (-) headaches, (-) head injury or deformity, (-) visual changes, (-) eye pain, (-) double or blurred vision, (-) hearing changes, (-) tinnitus, (-) vertigo, (-) use of hearing aids, (-) frequent colds, (-) nasal allergies. Ears, Nose, Mouth, Throat: (-) hearing changes, (-) tinnitus, (-) vertigo, (-) dizziness, (-) earache, (-) ear infection, (-) ear discharge, (-) use of hearing aids.

Respiratory: (-) cough, (-) hemoptysis, (-) cyanosis, (-) wheezing, (-) nocturnal choking or gasping.

Cardiovascular: (-) chest pain, (-) dizziness, (-) dyspnea with exertion, (-) edema, (+) high blood pressure, (-) irregular heartbeat, (-) orthopnea, (-) palpitations, (-) paroxysmal nocturnal dyspnea, (-) Syncope.
Cardiovascular: (+) high blood pressure.
Gastrointestinal: (-) abdominal pain, (-) heartburn, (-) constipation, (-) diarrhea, (-) nausea, (-) vomiting, (-) hematochezia, (-) melena, (-) change in bowel habits.

Genitourinary: (-) dysuria, (-) frequency, (-) urgency, (-) hesitancy, (-) polyuria, (-) nocturia, (-) hematuria, (-) urinary incontinence, (-) flank pain, (-) change in urinary habits.

Musculoskeletal: (-) muscle pain, (-) joint pain, (-) bone pain.

Peripheral Vascular: (-) intermittent claudication, (-) cramps, (-) varicose veins, (-) thrombophlebitis.

Neurological: (-) numbness, (-) tingling, (-) tremors, (-) seizures, (-) vertigo, (-) memory loss, (-) any focal or diffuse neurological deficits.

Endocrine: (-) heat or cold intolerance, (-) excessive sweating, (-) excessive thirst, (-) excessive hunger, (-) excessive urination, (-) hirsutism, (-) change in ring or shoe size.

Hematologic/Lymphatic: (-) anemia, (-) easy bruising, (-) excessive bleeding, (-) history of blood transfusions.

PHYSICAL EXAM:
Vitals:
BP: 133/82(Left Arm)(Standing)
Pulse: 70(Left brachial)(Standing)

Height: 5′ 6″
BSA: 0
BP: 154/89(Left Arm)(Supine)
Pulse: 58(Left brachial)(Supine)

General Appearance: The patient is an extremely pleasant 66 year old female who looks younger than her stated age. is well developed and well nourished in no apparent distress. Her body habitus is obese. Her mood is normal.
HEENT: Normocephalic and atraumatic. Pupils are equally round and reactive to light and accommodation. Extraocular muscles are intact. Patient’s neck is supple with no jugular venous distention, left carotid bruit was heard and carotid pulses are +2/2. Normal carotid artery upstroke bilaterally. Palpation is not painful and no thyromegaly nor lymphadenopathy can be appreciated.
Respiratory: Clear to auscultation bilaterally without wheezes or rhonchi. No intercostal retractions or accessory muscle use were noted.
Cardiovascular: Regular heart rate and rhythm. Cardiac point of maximal impulse at left fifth intercostal space mid-clavicular line. Normal S1, S2 with physiologic splitting of S2. No murmurs, thrills, rubs, gallops, or clicks were heard.
Gastroenterology: Abdomen is soft non-tender and non-distended. Positive bowel sounds, no hepatomegaly or splenomegaly was noted. No bruits were heard.
Extremities: Pulses were 2+ throughout bilaterally. No cyanosis, edema or clubbing.
Musculoskeletal: Motor strength is appropriately intact throughout bilaterally.
Neurologic: Patient is alert and oriented x3 with deep tendon reflexes appropriately intact throughout bilaterally, non-focal.
Psychiatric: Patient is conscious, cooperative, and well-oriented to time, place, and person. There are no mood swings or psychotic features. Patient’s insight is good. Memory and judgement are intact.
Skin: No skin rash, subcutaneous nodules, lesions or ulcers observed.
DIAGNOSTIC DATA:

ELECTROCARDIOGRAM: Date performed: Feb 7, 2016.
Indication: Occasional shortness of breath, Uncontrolled hypertension.
Interpretation: Rate: 51 bpm; Rhythm: Sinus bradycardia and low voltage limb leads; Axis: Left axis deviation.
Conclusion: Abnormal ECG.

2D COLOR DOPPLER ECHOCARDIOGRAPHY:
Date: Feb 7, 2016 Indication: Recurrent shortness of breath, Abnormal EKG.
Technically difficult study.

Findings:
Left atrium: Dimension: 4.3 cm. (Men: 3-4 cm/Women: 2.7-3.8 cm). It is mildly dilated.
Left ventricle:
-LVIDd = 3.6 cm (Men:4.2-5.9 cm/Women: 3.9-5.3cm).
-LVIDs = 2.4 cm (2.0-4.1 cm).
-IVS = 0.8 cm (0.6-1.1 cm).
-LVPWd = 0.8 cm (0.6-1.1 cm).

Right atrium: Normal in size and shape and shows no signs of ASD, mass or thrombus.
Right ventricle: Normal in size and shape and shows no signs of VSD, mass or thrombus.

Left ventricle ejection fraction: 60 %.

Pericardium: No effusion or calcification.

TREADMILL STRESS TEST/W STRESS ECHOCARDIOGRAPHY.
Date: Aug 2, 2015. Indication: Occasional shortness of breath, Abnormal EKG
Risk and benefits of exercise stress test including but not limited to myocardial infarction, vascular compromise and death were explained to Ms. PINCHEVSKIY in detail. The patient asked appropriate questions. All questions were answered. The patient wished to proceed and gave her informed consent.

Protocol: Standard Bruce protocol.

Procedure:
STAGE I (Min 0 to 2:50): Min: 1 . MPH: 1.7. Grade: 10 %. MET: 1-5. BP: 140/85, Pulse: 104, O2 Sat: 97.

Results:
Maximal Predicted Heart Rate: 155 bpm.
Peak heart rate achieved: 126 bpm.
Maximal heart rate achieved: 81 % of predicted heart rate.
Average O2 saturation throughout the study: 97 %.
Total Minutes: 3.

Clinical response:
Peak exercise electrocardiogram revealed no significant ischemic changes and occasional APCs.

Stress echocardiography:
Revealed normal left ventricular function at rest with an adequate increase in left ventricular function in response to exercise.

Summary: The patient exercised according to the BRUCE protocol for a total of 3 minutes, achieving a peak heart rate of 126 bpm, 81% of the maximum predicted heart rate. Electrocardiogram showed no significant ST-T changes. Dysrrhythmias were seen as mentioned above.
Symptoms at peak exercise: generalized fatigue.
The study was inconclusive.

Conclusion:
Response to exercise: Stress testing performed today was inconclusive given that the target exercise time duration was not achieved.
There is no evidence of inducible ischemia at the level of exercise achieved.
Electrocardiographic changes as stated above.
The patient had an inadequate exercise capacity.
Interval changes: No interval changes.

Recommendations: Recommend increasing exercise program and repeat stress test in 3-6 months. Patient declines APET.

CAROTID ARTERY DUPLEX SCAN:
Date of Study: Jul 5, 2016.
Indication: Left carotid bruit.

Measurements:
Left:
CCA distal peak velocity: 66 cm/sec.
CCA end diastolic velocity: 19 cm/sec.
ICA distal peak velocity: 70 cm/sec.
ICA end diastolic velocity: 24 cm/sec.
ECA distal peak velocity: 90 cm/sec.
ECA end diastolic velocity: 12 cm/sec.
Left vertebral artery showed antegrade flow.
ICA/CCA: 1.1.
Right:
CCA distal peak velocity: 72 cm/sec.
CCA end diastolic velocity: 20 cm/sec.
ICA distal peak velocity: 45 cm/sec.
ICA end diastolic velocity: 19 cm/sec.
ECA distal peak velocity: 97 cm/sec.
ECA end diastolic velocity: 23 cm/sec.
Right vertebral artery showed antegrade flow.
ICA/CCA: 0.6.

Impression/Comments:

Findings: Bilateral mild plaque.
Bilateral simple thyroid nodules measuring less than 1cm.

Comments: No change compared with previous study.

Plan:
Non-obstructive disease.
Will intensify medical therapy.

LOWER EXTREMITIES VENOUS DOPPLER: Sep 6, 2015.
Indication: Occasional shortness of breath, trace to 1+ bilateral leg edema.
Impression: Normal venous flow with normal collapse with compression. Normal augmentation of venous flow with calf compression. No evidence of venous insufficiency with valsalva manuever or abdominal pressure. Normal lower extremities.
No evidence of deep venous thrombosis or venous outflow obstruction of the lower extremities by duplex scanning.

RENAL ARTERY-AORTA DUPLEX SCAN: Jul 5, 2015.
Indication: Uncontrolled hypertensive heart disease without heart failure (402.00).

Measurements:
Left Renal Peak Systolic Velocity:
Proximal: 0.86 m/s [<1.0].
Mid: 0.64 m/s [<1.0].
Distal: 0.76 m/s [<1.0].
Renal/Aortic Ratio: 0.7. [<3.5].
Right Renal Peak Systolic Velocity:
Proximal: 0.44 m/s [<1.0].
Mid: 0.63 m/s [<1.0].
Distal: 0.55 m/s [<1.0].
Renal/Aortic Ratio: 0.5. [<3.5].

Aorta:
Proximal Aortic Diameter: 1.8 cm.
Mid Aortic Diameter: 1.5 cm.
Distal Aortic Diameter: 1.2 cm.
Aortic Peak Systolic Velocity: 1.21 m/s.

Kidney:
Left:
kidney length: 12.6 cm [8.5-15.0 cm].
Kidney Width: 5.9 cm. ( 4.5-5.0 cm].
Kidney Depth (trans): 4.9 cm. [4.5-5.0].
Cortical Thickness: 1.2 cm. [1.1 cm].
Parenchymal Flow /Waveform:
Upper Early Systolic Peak Present.
Mid Early Systolic Peak Present.
Lower Early Systolic Peak Present.
Resistive Index: 0.61 [<0.75] (PSV-EDV/PSV).

Right:
kidney length: 10.1 cm [8.5-15.0 cm].
Kidney Width: 5.4 cm. ( 4.5-5.0 cm].
Kidney Depth (trans): 4.7 cm. [4.5-5.0].
Cortical Thickness: 1.5 cm. [1.1 cm].
Parenchymal Flow /Waveform:
Upper Early Systolic Peak Present.
Mid Early Systolic Peak Present.
Lower Early Systolic Peak Present.
Resistive Index: 0.64 [<0.75]
(PSV-EDV/PSV).

Findings: Abnormal. Mild hydronephrosis, left kidney.

Technical impression: Abnormal study. Mild hydronephrosis, left kidney. Recommend follow up with Dr. Navon.

ABDOMINAL AORTA DUPLEX SCAN:
Date: Jun 21, 2015 Indication: Indication: Hypertension (401.1).

Aorta:
Proximal Aortic Diameter: 2.1 cm.
Proximal Aortic Peak Systolic Velocity: 0.98 m/s.
Mid Aortic Diameter: 1.4 cm.
Mid Aortic Peak Systolic Velocity: 1.44 m/s.
Distal Aortic Diameter: 1.1 cm.
Distal Aortic Peak Systolic Velocity: 1.12 m/s.

Technical impression:
Within normal limits.
Mild plaque seen in abdominal aorta.

Other:
LIVER AND GALLBRLADDER ULTRASOUND
Date: 02/21/2016
Indication: Increased LFTs
Impression: Study within normal limits.

Colonoscopy: No colonoscopy has ever been performed. She declines to have one.
Mammogram: No recent mammogram has been performed.
Pap Test: No recent pap smear has been performed.

————————————————————————————————————————————————————
DIAGNOSIS/ASSESSMENT:

HIGH RISK, NON COMPLIANT PATIENT.

LEFT CAROTID BRUIT.
Non obstructive disease per carotid artery Duplex scan. Optimal lipid profile, recommended.

HYPERTENSION.
No evidence of left ventricular hypertrophy, renal artery stenosis or abdominal aortic aneurysm per diagnostic studies. Adjust medications today. Patient to monitor her blood pressure twice daily and provide me with the records. Target systolic blood pressure in the 110-120 mmHg range recommended. Low salt, healthy diet and daily aerobic exercise advised.

HYPERLIPIDEMIA.
LDL 62 mg/dL, TG 96 mg/dL and HDL 64 mg/dL on 02/07/16. Low fat, healthy diet advised.

DIABETES MELLITUS TYPE 2.
Blood Glucose 142 mg/dL per labs on 06/05/16. HbA1c 6.8% on 02/07/16. Low carbohydrate, healthy diet advised. Defer management to her Internist.

ELEVATED LFTs.
AST 51 U/L, ALT 47 U/L per labs on 06/05/16. Ultrasound of the liver and gallbladder was within normal limits. Recommend follow up with a gastroenterologist.

OTHER:
– GERD. Recommend that the patient avoid eating for a few hours prior to going to bed, and sleep with the head of her bed elevated at a 45 degree angle. Defer management to her internist.
– Mild hydronephrosis of the left kidney per ultrasound, as outlined above. Recommend follow up with Dr. Navon.

DISCUSSION:

PLAN:
Medication changes:
Trial of Clonidine 0.1 mg PO QHS, hold if sBP < 110 mm Hg.

Procedures performed today: Carotid artery duplex scan.

Diet: Patient advised to follow a healthy low fat, salt and carbohydrate diet.

Exercise recommendations: Regular exercise is strongly recommended. Recommend gradual increase in daily aerobic exercise.

Hypertension Instructions: The patient was instructed to monitor their blood pressure twice daily and provide me with the records.We discussed medication compliance in length. She understands that she is to call the office if she needs a refill of hypertension medications.

Follow Up: The patient was advised to return to the office for follow up in 1 month to monitor blood pressure and medication changes. Return earlier if she has any medical problems.

Emergency recommendations: The patient was advised to call 911 or go to the emergency room if the patient’s condition worsens or does not improve.

——————————————————————————————————————————————————-

Changed/Discontinued Medication(s):
Discontinued By Other MD: DIOVAN 320 MG TABLET
Discontinued By Other MD: METOPROLOL SUCC ER 100 MG TAB
Check in time: 08:38 AM Check out time: 10:03 AM

Electronically signed: 07/06/2016 09:48 AM BENZUR, URI

G8427 Med.with dosage and verification documented; 1036F CURRENT TOBACCO NON-USER CAD CAP COPD PV DM; 93880 Extracranial arteries study, compl; 99213 Office/outpatient visit, est, mod; G8419 BMI abnormal. No followup plan documented

Uri M. Ben-Zur, M.D., F.A.C.C.
Interventional Cardiology / Invasive Electrophysiology

18200 Ventura Blvd
Tarzana, CA 91356
Phone (818) 986-0911 Fax (818) 986-9301

Date of visit: 07/05/2016
Reason for Visit:
Requesting Physician:
I had the opportunity to evaluate on the date stated above. I have reviewed the past medical history, symptoms and current therapy. In addition, I have examined the patient and based on my findings have provided my overall impression, outlining my treatment and plans in the summary below.

CHIEF COMPLAINT /HISTORY OF PRESENT ILLNESS:

Mis an extremely pleasant 66 year old male with a past medical history of sick sinus syndrome s/p pacemaker and highly symptomatic paroxysmal atrial fibrillation, s/p atrial fibrillation ablation on 10/23/13 and s/p successful DCCV on 03/05/2014 with multiple prior attempts for recurrent atrial flutter. He also has a history of Diabetes Mellitus type II and morbid obesity.

The patient presents today for advanced cardiac electrophysiologic follow-up.

The patient complains of occasional shortness of breath with exertion. He can walk 2 blocks before developing shortness of breath. This symptom has existed for an extended period of time and has been stable. It is mild in severity. No associated symptoms noted.

The patient denies chest pain, palpitations, dizziness, syncope.

The patient’s blood pressure averages 115/68 mmHg according to his home monitor. His blood sugar levels range from 127 to 130 mg/dL according to his home monitor. Mr. LEBEDEFF is following an exercise program. He follows a healthy diet.

The patient is on chronic anticoagulation therapy. The patient monitors his INR at home.

At the time of his last visit, no medication changes were made.

states that he is stable.
PAST MEDICAL HISTORY:
Cardiovascular:
Atrial Fibrillation. Paroxysmal.
Atrial Flutter.
Hyperlipidemia.
Hypertensive heart disease without CHF, controlled.
Tachy-brady dysrhythmia.
Hematology/Lymphatic:
Gilbert’s Syndrome.
Endocrine:
Diabetes mellitus type 2.
Trauma or Toxins:
Motor Vehicle Accident. 06/23/15.
SURGICAL HISTORY:
Hernia repair in 1993
Cholecystectomy in 1983
Cardiac angiography on 10/12/2005 showed non-obstructive disease
S/P Pacemaker implant 04/18/2008.
10/23/13. Comprehensive electrophysiology study and is status post radiofrequency ablation of atrial fibrillation/cardioversion/successful pulmonary vein isolation with confirmation of entrance and exit block.
-Mitral valve flutter ablation.
Additional foci of ablation, GP.
Additional foci of ablation, ligament of Marshall.
Pulmonary vein reconnection/Successful PVI with confirmation of entrance and exit block/Additional mechanism ablation, GP/Additional macular ablation ectopic atrial rhythm/Additional negative ablation left atrial roof line with bidirectional block/Additional linear lesion caval tricuspid isthmus creating bidirectional block). 02/05/14
DCCV 03/05/2014 successful.
DCCV 08/06/14
Pacemaker pulse generator removal and new pulse generator implantation 02/17/16.

CURRENT MEDICATIONS:
1 Spironolactone 25 Mg Tablet SIG: 1 tab daily
2 Pravachol 40 Mg Tablet SIG: 1/2 TAB QD
3 Sotalol 80 Mg Tablet SIG: Take 1 tablet twice a day
4 Bystolic 2.5 Mg Tablet SIG: Take 1 by mouth twice daily
5 K-dur 10 Meq Tablet SIG: take one on the days he takes Lasix.
6 Lasix 20 Mg Tablet SIG: 2 tablet PO PRN if SBP > 140 mmHg
7 Metformin Hcl 500 Mg Tablet SIG: 2 tablets PO QAM, 1 tablet PO QPM
8 Verapamil 120 Mg Tablet SIG: Take 1 tab by mouth twice a day
9 Melatonin 10 Mg Capsule (OTC) SIG: Patient unsure of dose
10 Zolpidem Tart Er 12.5 Mg Tab (Other MD) SIG: 1 tablet PO QHS
11 Vitamin D2 2,000 Unit Tablet (Other MD) SIG: Take 1 tab by mouth once daily
12 Coumadin 1 Mg Tablet (Other MD) SIG: 3/2/2 mg alt PO QD

ALLERGIES / INTOLERANCES:
Aliphatic Alcohols, Olmesartan, Penicillins, sulfamethoxazole, trimethoprim

SOCIAL HISTORY:
Marital Status: The patient is married.
Smoking/tobacco use: No history of smoking.
Alcohol: The patient drinks alcoholic beverages. He drinks red wine socially.
Recreational drug use: He denies recreational drug use.
Caffeine Intake: He does not drink coffee, tea, soda or any other caffeinated drinks and beverages.
Occupation: Clergy.

FAMILY HISTORY:
The patient’s father died at age 83, history of congestive heart failure.
The patient’s mother died at age 68, history of congestive heart failure.
REVIEW OF SYSTEMS:
Constitutional Symptoms: (-) fever, (-) chills, (-) night sweats, (-) fatigue, (-) weakness, (-) changes in appetite or weight.

Head: (-) headaches, (-) head injury or deformity, (-) visual changes, (-) eye pain, (-) double or blurred vision, (-) hearing changes, (-) tinnitus, (-) vertigo, (-) use of hearing aids, (-) frequent colds, (-) nasal allergies. Ears, Nose, Mouth, Throat: (-) hearing changes, (-) tinnitus, (-) vertigo, (-) dizziness, (-) earache, (-) ear infection, (-) ear discharge, (-) use of hearing aids. Neck: (-) swollen glands, (-) enlarged thyroid, (-) neck pain.

Respiratory: (+) cough, excessive mucus in am.
Respiratory: (+) cough, excessive mucus in am.
Cardiovascular: (-) chest pain, (-) dizziness, (+) dyspnea with exertion, (+) edema, (-) high blood pressure, (-) irregular heartbeat, (-) orthopnea, (-) palpitations, (-) paroxysmal nocturnal dyspnea, (-) Syncope.
Cardiovascular: (+) dyspnea with exertion, (+) edema.
Gastrointestinal: (-) abdominal pain, (-) heartburn, (-) constipation, (-) diarrhea, (-) nausea, (-) vomiting, (-) hematochezia, (-) melena, (-) change in bowel habits.

Musculoskeletal: (-) atrophy, (-) crepitations, (-) deformity, (+) joint pain of right knee.
Musculoskeletal: (+) joint pain of right knee.
Peripheral Vascular: (-) intermittent claudication, (-) cramps, (-) varicose veins, (-) thrombophlebitis.

Neurological: (-) numbness, (-) tingling, (-) tremors, (-) seizures, (-) vertigo, (-) memory loss, (-) any focal or diffuse neurological deficits.

Endocrine: (-) heat or cold intolerance, (-) excessive sweating, (-) excessive thirst, (-) excessive hunger, (-) excessive urination, (-) hirsutism, (-) change in ring or shoe size.

Hematologic/Lymphatic: (-) anemia, (-) easy bruising, (-) excessive bleeding, (-) history of blood transfusions.

PHYSICAL EXAM:
Vitals:
BP: 133/81(Left Arm)(Sitting)
Pulse: 62(Left brachial)(Standing)(Regular)

Weight: 305 lbs 12 oz
Height: 6′ 1″
BMI: 40.33
BSA: 2.67
BP: 122/82(Left Arm)(Standing)
Pulse: 69(Left brachial)(Standing)(Regular)

General Appearance: The patient is an extremely pleasant 66 year old male who looks younger than his stated age. Father Lebedeff is well developed and well nourished in no apparent distress. His body habitus is morbidly obese, his mood is normal.
HEENT: Normocephalic and atraumatic. Pupils are equally round and reactive to light and accommodation. Extraocular muscles are intact. Patient’s neck is supple with no jugular venous distention, no carotid bruit was heard and carotid pulses are +2/2. Normal carotid artery upstroke bilaterally. Palpation is not painful and no thyromegaly nor lymphadenopathy can be appreciated.
Respiratory: Right sided crackles and wheezing. No intercostal retractions or accessory muscle use were noted.
Cardiovascular: Cardiac point of maximal impulse at left fifth intercostal space mid-clavicular line. Normal S1, S2 with physiologic splitting of S2. No murmurs, thrills, rubs, gallops, or clicks were heard.
Gastroenterology: Abdomen is soft non-tender and non-distended. Positive bowel sounds, no hepatomegaly or splenomegaly was noted. No bruits were heard.
Extremities: Pulses were 2+ throughout bilaterally. 1+ lower extremity edema bilaterally.
Musculoskeletal: Motor strength is appropriately intact throughout bilaterally.
Neurologic: Patient is alert and oriented x3 with deep tendon reflexes appropriately intact throughout bilaterally, non-focal. Alert and Oriented: x3. No focal weakness. Grossly intact.
Psychiatric: Patient is conscious, cooperative, and well-oriented to time, place, and person. There are no mood swings or psychotic features. Patient’s insight is good. Memory and judgement are intact.
Skin: No skin rash, subcutaneous nodules, lesions or ulcers observed. Incision is clean, dry, and intact with no signs of infection.
DIAGNOSTIC DATA:

Encounter long term anticoagulant. Date: Jun 7, 2016.
INR: 2.5.
Current Dose: : 3/2/2 mg PO QD alternating dose.
Therapeutic Goal/INR: 2.0 – 3.0.
Medication adjustments: Continue same Coumadin dose.
Next INR test: Aug 2, 2016.

CHAD2DS SCORE:
Hypertension 1 point.
Diabetes Mellitus: 1 point.
Total Score: 2. Antithrombotic therapy is recommended for stroke prevention.

ELECTROCARDIOGRAM: Date performed: Jul 5, 2016.
Indication: Occasional shortness of breath and worsening leg edema.
Interpretation: Rate: 60 bpm; Rhythm: Apaced with capture, prolonged QT, Poor R wave progression and low voltage limb leads; Axis: Left axis deviation; S/P Anteroseptal wall myocardial infarction.
Conclusion: Abnormal ECG.

2D COLOR DOPPLER ECHOCARDIOGRAPHY:
Date: Jul 5, 2016 Indication: Occasional shortness of breath, atrial arrhythmias.

Findings:
Left atrium: Dimension: 4.9 cm. (Men: 3-4 cm/Women: 2.7-3.8 cm). It is mildly dilated.
Left ventricle:
-LVIDd = 5.2 cm (Men:4.2-5.9 cm/Women: 3.9-5.3cm).
-LVIDs = 3.8 cm (2.0-4.1 cm).
-IVS = 1.2 cm (0.6-1.1 cm).
-LVPWd = 1.2 cm (0.6-1.1 cm).
Ventricular thickness: There is moderate LV concentric hypertrophy.

Right atrium: Normal in size and shape and shows no signs of ASD, mass or thrombus.
Right ventricle: Normal in size and shape and shows no signs of VSD, mass or thrombus.

Left ventricle ejection fraction: 60 %.

Pericardium: No effusion or calcification.
Venous: Inferior vena cava: Normal diameter with normal respiratory variation.
Pacemaker/ICD lead: Pacemaker/ICD lead in right heart.

CAROTID ARTERY DUPLEX SCAN:
Date of Study: Sep 16, 2013.
Indication: Dizziness S/P Fall, Right carotid bruit.

Measurements:
Left:
CCA distal peak velocity: 123 cm/sec.
CCA end diastolic velocity: 40 cm/sec.
ICA distal peak velocity: 55 cm/sec.
ICA end diastolic velocity: 26 cm/sec.
ECA distal peak velocity: 99 cm/sec.
ECA end diastolic velocity: 31 cm/sec.
Left vertebral artery showed antegrade flow.
ICA/CCA: 0.4.
Right:
CCA distal peak velocity: 57 cm/sec.
CCA end diastolic velocity: 22 cm/sec.
ICA distal peak velocity: 64 cm/sec.
ICA end diastolic velocity: 27 cm/sec.
ECA distal peak velocity: 85 cm/sec.
ECA end diastolic velocity: 22 cm/sec.
Right vertebral artery showed antegrade flow.
ICA/CCA: 1.1.

Impression/Comments:
Left:
Left bulb plaque: less than 10%.
Right:
Right bulb calcified plaque: less than 30%.

Plan:
Non-obstructive disease.
Will intensify medical therapy.

LOWER EXTREMITIES VENOUS DOPPLER: Oct 4, 2011.
Indication: Occasional shortness of breath, 2+ bilateral leg edema.
Findings: Normal venous flow with normal collapse with compression. Normal augmentation of venous flow with calf compression. No evidence of venous insufficiency with valsalva manuever or abdominal pressure. Normal lower extremities.
No evidence of deep venous thrombosis or venous outflow obstruction of the lower extremities by duplex scanning.
Baker’s cyst seen in the right popliteal area.

RENAL ARTERY-AORTA DUPLEX SCAN: Apr 24, 2014.
Indication: Hypertension (401.1).

Measurements:
Left Renal Peak Systolic Velocity:
Proximal: 0.51 m/s [<1.0].
Mid: 0.85 m/s [<1.0].
Distal: 0.6 m/s [<1.0].
Renal/Aortic Ratio: 1. [<3.5].
Right Renal Peak Systolic Velocity:
Proximal: 0.91 m/s [<1.0].
Mid: 1.21 m/s [<1.0].
Distal: 0.6 m/s [<1.0].
Renal/Aortic Ratio: 1.4. [<3.5].

Aorta:
Proximal Aortic Diameter: 2.2 cm.
Mid Aortic Diameter: 1.7 cm.
Distal Aortic Diameter: 1.3 cm.
Aortic Peak Systolic Velocity: 0.88 m/s.

Kidney:
Left:
kidney length: 11.4 cm [8.5-15.0 cm].
Kidney Width: 5.5 cm. ( 4.5-5.0 cm].
Kidney Depth (trans): 4.8 cm. [4.5-5.0].
Cortical Thickness: 1.7 cm. [1.1 cm].
Parenchymal Flow /Waveform:
Upper Early Systolic Peak Present.
Mid Early Systolic Peak Present.
Lower Early Systolic Peak Present.
Resistive Index: 0.71 [<0.75] (PSV-EDV/PSV).

Right:
kidney length: 11.5 cm [8.5-15.0 cm].
Kidney Width: 5.5 cm. ( 4.5-5.0 cm].
Kidney Depth (trans): 4.9 cm. [4.5-5.0].
Cortical Thickness: 1.5 cm. [1.1 cm].
Parenchymal Flow /Waveform:
Upper Early Systolic Peak Present.
Mid Early Systolic Peak Present.
Lower Early Systolic Peak Present.
Resistive Index: 0.64 [<0.75]
(PSV-EDV/PSV).

Technical impression: Abnormal study. Bilateral multiple calculi seen within the renal parenchyma measuring less than 1cm. (1) Simple cyst seen in the left kidney measuring 2.6cm x 1.8cm x 2.2cm. Recommend follow up with Dr. Navon..

PACEMAKER INTERROGATION REPORT: Date of Interrogation: Jul 5, 2016.
Implant Indication: Sick Sinus Syndrome.
Implant date: 02/17/16.
Magnet Rate: 100 bpm.
Model: St Jude Assurity.
Battery status: 3.04 V.
Estimated battery life: 9-11 years.

Atrial.
Atrial threshold: 0.5 V at 0.4 ms.
Atrial impedance: 460 Ohms.
Right Ventricular threshold: 0.5 V at 0.4 ms.
Right Ventricular impedance: 490 Ohms.

Atrial Pacing: 26 %.
Ventricular pacing: 1 %.
Mode switching episodes:

Interrogation Assessment: Device function normal.
191 episodes of EMI, all short in duration. Noise seen on A & v leads.

Treadmill stress test with echocardiographic imaging 4/25/2008: indication: chest pain.
The patient was told the risk and benefits of exercise stress test including but not limited to myocardial infarction, vascular compromise and death. The patient asked appropriate questions. All questions were answered and the patient wished to proceed and gave his informed consent. The patient completed 3 minutes 41 seconds on the Bruce Protocol achieving a heart rate of 104 beats per minutes, which represents approximately 64% of predicted maximal heart rate. The patient did not complain of any chest pain. He did not complain of shortness of breath or dizziness. Exercise test was terminated secondary to generalized fatigue when patient achieved 64% of predicted maximal heart rate.
Electrocardiogram showed no significant ST changes. Atrial premature contractions/ ventricular premature contractions / dysrhythmias were not seen. Normal left ventricular function pre and post exercise and no inducible ischemia. The oxygen saturation was more than 95% throughout exercise test.
Previous Stress Echocardiography with color flow Doppler and Doppler echo on 8/2/2007 reported normal chamber dimensions, right ventricular systolic pressure 24 mm Hg, interventricular septum 1.3 cm, posterior wall 1.2 cm. Ejection fraction 65%. Today’s stress echocardiography reveals normal left ventricular function at rest with an adequate increase in left ventricular function in response to exercise. Doppler echo was done to evaluate the blood flow across the mitral, tricuspid,aortic,pulmonic valve(s). Stress echocardiography showed: Ascending aorta 3.2 cm, aortic root 2.1 cm, interventricular septum 1.3 cm, posterior wall 1.2 cm, left ventricular internal dimension diastole 4.9 cm, left ventricular internal dimension systole 2.9 cm, left atrium 5.2 cm, right ventricular systolic pressure 26 mmHg, mild anterior free space, trace mitral regurgitation, E to A reversal suggestive of diastolic dysfunction, mild concentric left ventricular hypertrophy. Ejection fraction 65%.
Impression: Inconclusive exercise stress/ echocardiography, given that the target exercise time was not achieved. Adequate oxygen saturation. Negative electrocardiographic changes. Recommend increase program and repeat stress test in 6 months.

Duplex Scan of Abdominal Aorta 9/7/2007: Indication: Hypertension – controlled
Proximal Aortic Diameter 2.3 cm. Peak Systolic Velocity 0.61 m/sec
Mid Aortic Diameter 1.7 cm. Peak Systolic Velocity 0.5 m/sec
Distal Aortic Diameter 1.3 cm. Peak Systolic Velocity 0.61 m/sec
Aortic Peak Systolic Velocity 0.61 m/s
Impression: Normal study
Additional Findings: Technically difficult study due to patient’s body habitus.

Lower Extremity Artery Duplex 5/23/2008
Indication: pain in limb and bilateral trace to 1+ edema
Criteria for stenosis:
% Stenosis — Velocity Ratio
Normal <1.5:1
30% – 49% –> 1.5: 1-2: 1
50% – 75% –> 2: 1-4: 1
>75% is >4:1
Occlusion –> No color Saturation
Normal Range Artery Velocity:
Artery — Velocity (m/sec)
External Iliac 97.6-141
Common Femoral 89.2-139
Superficial Femoral (proximal) 77.2-104.4
Superficial Femoral (distal) 79.5-107.7
Popliteal 55.3-82.3

Right Side m/s Waveform (RT) Comment (RT) Left Side m/s Waveform (LT) Comment (LT)
Iliac
Common Femoral 1.11 triphasic plaque <10% 1.08 triphasic plaque <10%
Profunda Femoris .46 triphasic plaque <10% .46 triphasic plaque <10%
Superficial Femoral (proximal) .76 triphasic plaque <10% .75 triphasic plaque <10%
Superficial Femoral (mid) .78 triphasic plaque <10% .92 triphasic plaque <10%
Superficial Femoral (distal) 1.04 triphasic plaque <10% .77 triphasic plaque <10%
Popliteal .49 triphasic plaque <10% .47 triphasic plaque <10%
Posterior Tibial
Anterior Tibia
Dorsalis Pedis

Technical Impression: Within normal limits
Comments: Incidental finding: Visualized baker cyst on the right popliteal area.
Other:
UPPER EXTREMITY VENOUS ULTRASOUND (Limited Study)
Date: 02/16/2016
Indication: Shortness of breath and pre-operative evaluation
Impression: Patent subclavian and cephalic veins
Comments: Right side is more visible than left.

CT ANGIOGRAPHY CHEST WITH CONTRAST 09/25/13
Impression:
1. There is no left intra atrial thrombus
2. Surgical changes of the chest
3. 3mm non-specific right lower lobe pulmonary nodule.

THYROID ULTRASOUND
Date: 10/12/2012
Indication: H/O Thyroid nodule
Impression: (1) Complex nodule seen in the left thyroid gland measuring less than 1cm.
Comments: Recommend follow up with Dr. Nourparvar.

Urinalysis Report: Date: Jul 7, 2015.
Indication: Dysuria.
Leukocytes: Small amount of Leukocytes present.
Nitrite: Negative.
Urobilinogen: (Normal 0.2 – 1).
Protein: Trace amount present.
Ph: 5.
Blood: Negative Non-Hemolyzed blood present.
Specific Gravity: 1.030.
Ketone: Trace.
Bilirubin: Small.
Glucose: Negative.
Recommendations: F/u with Dr. Navon.
C&S today.

Last colonoscopy: 08/12/2008, 4 polyps were removed
Last prostate exam / urological evaluation: 2007, reportedly was normal. Last PSA:2007, reportedly was normal
Pneumovax vaccine 11/07/2006.
FLU VACCINATION: Sep 1, 2015.

————————————————————————————————————————————————————
DIAGNOSIS/ASSESSMENT:

PROLONGED VISIT. LONG DISCUSSION WITH THE PATIENT. MULTIPLE QUESTIONS ASKED AND ANSWERED.

CARDIAC PACEMAKER IN SITU.
S/p permanent pacemaker implantation given sick sinus syndrome. S/p pulse generator replacement on 02/17/16. Normal device function per interrogation today.

H/O RECURRENT SYMPTOMATIC ATRIAL FLUTTER WITH PAROXYMS OF RAPID VENTRICULAR RESPONSE POST ABLATION.
H/O PAROXYSMAL ATRIAL TACHYCARDIA.
MILDLY DILATED LEFT ATRIUM.
The patient was strongly advised to avoid stress, alcohol, caffeine and other stimulants, which may precipitate these conditions. He is to contact me if he has a recurrence of palpitations. Continue Coumadin.

SHORTNESS OF BREATH WITH EXERTION.
Multifactorial. Morbidly obese patient with multiple risk factors for coronary artery disease and recurrent atrial arrhythmias. Today’s EKG revealed A paced with capture, poor R wave progression, prolonged QT, low voltage limb leads, left axis deviation, s/p possible anteroseptal wall myocardial infarction, age undetermined. Echocardiography revealed normal left ventricular function, EF 60%. The patient was advised of the importance of cardiac risk factor modification, including optimal blood sugar, lipid profile, a healthy diet, weight loss and daily aerobic exercise. He is to contact me if this symptom worsens, or he develops new symptoms.

H/O RATE-RELATED CARDIOMYOPATHY.
Heart failure has been directly related to his atrial arrhythmias with paroxysms of rapid ventricular response. The patient is doing well post DCCV on 08/06/14. EF at 60%. The patient was advised of the importance of following a healthy diet, weight loss and daily aerobic exercise.

HYPERTENSION.
Controlled. Moderate concentric left ventricular hypertrophy per echocardiography. Recommend that the patient monitor his blood pressure twice daily and provide me with the records. Target systolic blood pressure in the 110-120 mmHg range recommended. Low salt, healthy diet advised.

HYPERLIPIDEMIA.
HDL 85 mg/dL, LDL 93 mg/dL and total cholesterol 204 mg/dL per labs on 06/07/16. The patient is on Pravachol. Defer labs and management to Dr. Ito.

LEG EDEMA.
The patient takes Lasix as needed. Recommend that he raise his lower extremities above heart level for 30 minutes, 3-4 times daily and follow a low salt diet.

DIABETES MELLITUS.
Hb A1c 6.9% per labs on 06/07/16. Low carbohydrate, healthy diet advised. Defer management to Dr. Ito.

OTHER:
– H/o nephrolithiasis per CT of the pelvis, per the patient’s account. The patient reports passing of stones and is currently asymptomatic. Defer to the patient’s urologist.
– Right knee pain. Surgical correction has been advised by his orthopedist, Dr. Mollar. The plan is to change his PM pulse generator prior to orthopedic procedure. Will discuss it with Dr. Mollar.
– H/o thyroid nodule. Follow-up thyroid ultrasound on 10/12/12 showed: (1) Complex nodule seen in the left thyroid gland measuring less than 1cm. Recommend follow up with Dr. Nourparvar.
– Lung nodule. 3 mm non specific right lower lobe pulmonary nodule per CT angiography of the chest 09/25/13. No follow up recommended given that the patient has no history of tobacco use. (Per radiology recommendations). Defer to Dr. Ito.
– Hand tremor. Stable. Defer to his neurologist.
– Morbid obesity. The patient was advised regarding the importance of weight loss, regular exercise, and a healthy diet for his overall cardiovascular health. Defer management to Dr. Ito.
– Anxiety/insomnia. Recommend practicing relaxation techniques. Continue medications. Defer to his internist.
– Sciatica. Counseled patient to not receive spinal epidural for pain management due to current anticoagulation therapy. Encouraged weight loss, healthy diet, and exercise. Defer management to his internist.
– Cough. Will defer management to Dr. Ito.

**The patient is intolerant to higher doses of Spironolactone and Metformin**.

COMPLEX PATIENT WITH MULTIPLE MEDICAL PROBLEMS. IT HAS BEEN VERY DIFFICULT TO MOTIVATE THE PATIENT TO IMPROVE HIS LIFESTYLE HABITS. PATIENT HAS BEEN STRONGLY ENCOURAGED TO LOSE WEIGHT.

DISCUSSION:

PLAN:
Medication changes: No.

Procedures performed today: EKG, Complete Echocardiogram, Pacemaker complete interrogation.

Diet: Patient advised to follow a healthy low fat, salt and carbohydrate diet.

Exercise recommendations: Regular exercise is strongly recommended. Recommend gradual increase in daily aerobic exercise.

Hypertension Instructions: The patient was instructed to monitor their blood pressure twice daily and provide me with the records.

Anticoagulation/ Anti-thrombin recommendations: The patient was advised that chronic anticoagulation therapy is recommended for his heart condition. Risks of chronic anticoagulation therapy include, but are not limited to, increased risk of bleeding complications including the possibility of intracranial bleeding, and increased risk of bleeding related to trauma. Given the patient’s increased risk for thromboembolic events, Coumadin therapy is recommended. Careful monitoring is extremely important with chronic anticoagulation therapy. If, during Coumadin therapy, the patient notices any evidence of bleeding or the patient is involved in a traumatic accident, the patient was advised to please notify my office immediately. The patient was advised to try to maintain a consistent intake of green vegetables per day to ensure that their INR levels do not fluctuate dramatically. A blood test called an “INR” will need to be checked every one to two weeks to ensure constant levels of Coumadin therapy.

Preventive Medicine: It is important that the patient follow up with their primary physician for preventative medicine follow ups including yearly prostate exam and annual physical exam.

Follow Up: The patient was advised to return to the office for follow up in 1 month or earlier if he has any medical problems.

Emergency recommendations: The patient was advised to call 911 or go to the emergency room if the patient’s condition worsens or does not improve.

——————————————————————————————————————————————————-
Changed/Discontinued Medication(s):
Changed By Other MD: COUMADIN 1 MG TABLET
Discontinued By Other MD: FLOVENT HFA 220 MCG INHALER MCG/ACTUATION – pt dc’d
Check in time: 09:13 AM Check out time: 10:24 AM

Electronically signed: 07/06/2016 03:23 PM BENZUR, URI

85610 Prothrombin time; 93000 Electrocardiogram, complete (ECG); 93306 echo 2Dw/doppler echo/color flow doppler; 93288 Pacer Check Dual; 99214 Office/outpatient visit, est, mod; G8427 Med.with dosage and verification documented; 1036F CURRENT TOBACCO NON-USER CAD CAP COPD PV DM; G8419 BMI abnormal. No followup plan documented

Uri M. Ben-Zur, M.D., F.A.C.C.
Interventional Cardiology / Invasive Electrophysiology

18200 Ventura Blvd
Tarzana, CA 91356
Phone (818) 986-0911 Fax (818) 986-9301
Date of visit: 07/05/2016
Reason for Visit:
Requesting Physician:
I had the opportunity to evaluat on the date stated above. I have reviewed the past medical history, symptoms and current therapy. In addition, I have examined the patient and based on my findings have provided my overall impression, outlining my treatment and plans in the summary below.

CHIEF COMPLAINT /HISTORY OF PRESENT ILLNESS:

Mis an extremely pleasant 75 year old male with a past medical history of paroxysmal atrial fibrillation, paroxysmal atrial flutter, coronary artery disease, ischemic cardiomyopathy, carotid artery disease, congestive heart failure, hypertension, hyperlipidemia and history of pulmonary embolus. He is accompanied today by his daughter.

The patient presents today for a second opinion evaluation regarding his management. He has a long and complicated history. He states that he has been feeling very weak and fatigued, and has progressively worsening shortness of breath. His daughter states that he underwent BiVD implant several months ago, but since the BiVD implant he has continued to get worse. Of note is that he was started on Amiodarone after the BiVD implant.

The patient also complains of occasional, non exertional left sided chest pain. He states that this symptom occurs rarely. The severity of this symptom is mild. No other associated symptoms noted.

The patient also complains of occasional dizziness with changes of position. The severity of this symptom is mild. No other associated symptoms noted.

The patient denies palpitations, syncope.

His blood pressure readings have been within normal limits at home. The patient does not follow an exercise program. He does not follow a specific diet.

At the time of his last visit, he was instructed to discontinue Carvedilol. He complied.

Overall, states that he is not feeling well.
PAST MEDICAL HISTORY:
Cardiovascular:
Atrial Fibrillation.
Atrial Flutter.
Cardiomyopathy, Ischemic.
Carotid artery disease.
Congestive Heart Failure.
Coronary Artery Disease. H/o multiple myocardial infarctions.
Hyperlipidemia.
Hypertension, benign essential.
Cerebro-vascular Accident. During endarterectomy.
Respiratory:
Pulmonary Embolism. 2012.
Genitourinary:
Benign Prostatic Hyperplasia.
Hyperuricemia.
Chronic kidney disease.
Malignancy:
Gastric cancer.
SURGICAL HISTORY:
Coronary artery bypass grafting x3, 1990.
Multiple coronary angiograms and angioplasties. Last angiogram 2014.
Left carotid endarterectomy, 2010.
Stomach surgery (for malignant ulcer), 2011.
Prostate surgery.
BiVD implant 2015.

CURRENT MEDICATIONS:
1 Amiodarone Hcl 200 Mg Tablet SIG: take one tablet daily
2 Clopidogrel 75 Mg Tablet SIG: take one daily
3 Digoxin 125 Mcg Tablet SIG: take one daily
4 Eliquis 2.5 Mg Tablet SIG: take one twice daily
5 Furosemide 40 Mg Tablet SIG: take one daily
6 Isosorbide Mn Er 30 Mg Tablet SIG: take one daily
7 Ranexa Er 1,000 Mg Tablet SIG: take one twice daily
8 Spironolactone 25 Mg Tablet SIG: take one daily
9 Tamsulosin Hcl 0.4 Mg Capsule SIG: take one daily
10 Ubiquinol 100 Mg Softgel SIG: 200 mg daily

ALLERGIES / INTOLERANCES:
No Known Drug Allergy

SOCIAL HISTORY:
Marital Status: The patient is married, with one son, and one daughter, both healthy.
Smoking/tobacco use: Discontinued 1990. He smoked 1.5 packs of cigarettes/day for several years.
Alcohol: The patient drinks alcoholic beverages socially.
Recreational drug use: He denies recreational drug use.
Caffeine Intake: One cup of coffee/day.
Stress Level: Low.
Occupation: Retired.

FAMILY HISTORY:
Father is deceased. He died at the age of 72. Cause of death unknown.
Mother is deceased. She died at the age of 53 due to CVA. H/o hypertension.
REVIEW OF SYSTEMS:
Constitutional Symptoms: (+) fatigue, (+) weakness.
Constitutional Symptoms: (+) fatigue, (+) weakness.
Integumentary: (-) rash, (-) lumps, (-) itching, (-) dryness, (-) acne, (-) discoloration, (-) recurrent skin infections, (-) changes in hair, nails or moles.

Respiratory: (-) cough, (-) hemoptysis, (-) cyanosis, (-) wheezing, (-) nocturnal choking or gasping.

Cardiovascular: (+) chest pain non-exertional, (+) dizziness, (+) dyspnea with exertion, (-) edema, (-) high blood pressure, (-) irregular heartbeat, (-) palpitations, (+) shortness of breath, (-) Syncope.
Cardiovascular: (+) chest pain non-exertional, (+) dizziness, (+) dyspnea with exertion, (+) shortness of breath.
Gastrointestinal: (-) abdominal pain, (+) constipation.
Gastrointestinal: (+) constipation.
Genitourinary: (-) dysuria, (-) frequency, (-) urgency, (-) hesitancy, (-) polyuria, (-) nocturia, (-) hematuria, (-) urinary incontinence, (-) flank pain, (-) change in urinary habits.

Musculoskeletal: (+) leg pain, (+) back pain.
Musculoskeletal: (+) leg pain, (+) back pain.
Peripheral Vascular: (-) intermittent claudication, (-) cramps, (-) varicose veins, (-) thrombophlebitis.

Neurological: (-) numbness, (-) tingling, (-) tremors, (-) seizures, (-) vertigo, (-) memory loss, (-) any focal or diffuse neurological deficits.

PHYSICAL EXAM:
Vitals:
BP: 118/65(Right Arm)(Supine)
Pulse: 73

Weight: 217 lbs
Height: 5′ 7″
BMI: 33.98
BSA: 2.15
BP: 141/74
Pulse: 67

General Appearance: The patient is an extremely pleasant 75 year old male who looks younger than his stated age. is well developed and well nourished in no apparent distress. His body habitus is obese. His mood is normal.
HEENT: Normocephalic and atraumatic. Pupils are equally round and reactive to light and accommodation. Extraocular muscles are intact. Patient’s neck is supple with no jugular venous distention, left carotid bruit was heard and carotid pulses are +2/2. Normal carotid artery upstroke bilaterally. Palpation is not painful and no thyromegaly nor lymphadenopathy can be appreciated.
Respiratory: Clear to auscultation bilaterally without wheezes or rhonchi. No intercostal retractions or accessory muscle use were noted.
Cardiovascular: Regular heart rate and rhythm. Cardiac point of maximal impulse at left fifth intercostal space mid-clavicular line. Normal S1, S2 with physiologic splitting of S2. No murmurs, thrills, rubs, gallops, or clicks were heard.
Gastroenterology: Abdomen is soft non-tender and non-distended. Positive bowel sounds, no hepatomegaly or splenomegaly was noted. No bruits were heard.
Extremities: Pulses were 2+ throughout bilaterally. No cyanosis, edema or clubbing.
Musculoskeletal: Motor strength is appropriately intact throughout bilaterally.
Neurologic: Patient is alert and oriented x3 with deep tendon reflexes appropriately intact throughout bilaterally, non-focal.
Psychiatric: Patient is conscious, cooperative, and well-oriented to time, place, and person. There are no mood swings or psychotic features. Patient’s insight is good. Memory and judgement are intact.
Skin: No skin rash, subcutaneous nodules, lesions or ulcers observed.
DIAGNOSTIC DATA:

ELECTROCARDIOGRAM: Date performed: Jul 3, 2016.
Indication: Worsening shortness of breath, end stage cardiomyopathy. Congestive heart failure, NYHA class III.
Interpretation: Rhythm: Asensed Vpaced with capture.
Conclusion: Abnormal ECG.

2D COLOR DOPPLER ECHOCARDIOGRAPHY:
Date: Jul 3, 2016 Indication: shortness of breath, weakness, fatigue.

Findings:
Left atrium: Dimension: 3.4 cm. (Men: 3-4 cm/Women: 2.7-3.8 cm).
Left ventricle:
-LVIDd = 6.2 cm (Men:4.2-5.9 cm/Women: 3.9-5.3cm).
-LVIDs = 5.4 cm (2.0-4.1 cm).
-IVS = 0.7 cm (0.6-1.1 cm).
-LVPWd = 0.7 cm (0.6-1.1 cm).
Wall kinesis: Apical akinesis. apical aneurysm. Severe left ventricle dysfunction. There is E-A flow reversal suggestive of diastolic dysfunction.

Right atrium: Normal in size and shape and shows no signs of ASD, mass or thrombus.
Right ventricle: Normal in size and shape and shows no signs of VSD, mass or thrombus.

Left ventricle ejection fraction: 15-20 %.

Pericardium: No effusion or calcification.
Venous: Inferior vena cava: Normal diameter with normal respiratory variation.
Pacemaker/ICD lead: Pacemaker/ICD lead in right heart.

CAROTID ARTERY DUPLEX SCAN:
Date of Study: Jul 5, 2016.
Indication: Dizziness, near syncope, left carotid bruit and history of severe CAD.

Measurements:
Left:
CCA distal peak velocity: 60 cm/sec.
CCA end diastolic velocity: 15 cm/sec.
ICA distal peak velocity: 95 cm/sec.
ICA end diastolic velocity: 33 cm/sec.
ECA distal peak velocity: 69 cm/sec.
ECA end diastolic velocity: 11 cm/sec.
Left vertebral artery showed antegrade flow.
ICA/CCA: 1.6.
Right:
CCA distal peak velocity: 58 cm/sec.
CCA end diastolic velocity: 15 cm/sec.
ICA distal peak velocity: 58 cm/sec.
ICA end diastolic velocity: 20 cm/sec.
ECA distal peak velocity: 91 cm/sec.
ECA end diastolic velocity: 20 cm/sec.
Right vertebral artery showed antegrade flow.
ICA/CCA: 1.

Impression/Comments:

Findings: Bilateral mild plaque.
(1) Complex nodule seen in the left thyroid gland measuring 1.1cm x 0.9cm x 1.2cm.

Plan:
Non-obstructive disease.
Will intensify medical therapy.

Follow up:
Follow up with Dr. Nourparvar recommended.

.
QUICK CHECK. Date: 07/03/2016
Indication: BIVD Device. Severe SOB. Fatigue. H/O severe cardiomyopathy
Impression: Normal device fucntion. PAF/ PAF flutter.

BIVD INTERROGATION REPORT: Date of Interrogation: Jul 5, 2016.
Implant Indication: Congestive Heart Failure.
Implant date: -2/27/2015.
Model: St Jude Quadra Assura.
Battery status:
Estimated battery life: 5.8 years.

Final Parameters:
Mode: DDD.
Lower rate: 60 bpm.

Interrogation Assessment: Device function normal.
Extended AV delays to promote intrinsic conduction..
Colonoscopy: Last colonoscopy was performed in 2011. Results were normal.
Prostate exam: Last urological exam was performed in 2016.
Patient’s Physicians:
Primary Cardiologist: Dr. Marwah.
Electrophysiologist: Dr. Mckenzie.

————————————————————————————————————————————————————
DIAGNOSIS/ASSESSMENT:

HIGH RISK, COMPLEX PATIENT, PROLONGED VISIT.

SHORTNESS OF BREATH/WEAKNESS/LEG EDEMA.
Progressive. Multifactorial. Patient with a history of severe coronary artery disease, ischemic cardiomyopathy, congestive heart failure, pulmonary embolism, atrial fibrillation, history of heavy tobacco use, on Amiodarone and betablocker therapy. EKG revealed A sensed V paced with capture. Apical akinesis, apical aneurysm, diastolic dysfunction, severe left ventricular dysfunction, EF 15-20% per echocardiography. Awaiting his medical records, including results of recent thallium. His BiVD was adjusted (extended AV delays to promote intrinsic conduction). Carvedilol was previously discontinued. Will follow him closely and consider further medication adjustments, (possibly discontinuing Amiodarone), if his symptoms do not improve. Low salt, healthy diet advised. Will follow him carefully.

ATYPICAL CHEST PAIN.
Minimally symptomatic. Cannot rule out cardiac etiology at this time. EKG revealed A sensed V paced with capture. Apical akinesis, apical aneurysm, diastolic dysfunction, severe left ventricular dysfunction, EF 15-20% per echocardiography. Awaiting his medical records, including results of recent thallium. He may be a candidate for intervention. Continue current medications for now. He is to contact me or emergency services if he has a recurrence of this symptom.

DIZZINESS.
LEFT CAROTID BRUIT.
Likely multifactorial. Orthostatic changes on physical examination today. Non obstructive disease per carotid artery Duplex scan today. Recommend that the patient rise slowly from a lying down/seated position, and remain well hydrated at all times. He is to contact me if this symptom worsens, or he develops new symptoms.

CORONARY ARTERY DISEASE/SEVERE ISCHEMIC CARDIOMYOPATHY.
S/p CABG x 3, and multiple angioplasties. Awaiting his records for review. EF 15-20% per echocardiography. Will optimize his medical therapy. The patient was advised of the importance of cardiac risk factor modification, including optimal blood pressure, lipid profile, a healthy diet, weight loss and exercise as tolerated. Will follow him carefully.

CONGESTIVE HEART FAILURE, NYHA CLASS III.
Continue diuretic therapy. Low salt, healthy diet advised.

PAROXYSMAL ATRIAL FIBRILLATION/PAROXYSMAL ATRIAL FLUTTER.
Will consider intervention, including RF ablation or AV nodal ablation depending on his clinical progress. Continue Eliquis, and Amiodarone for now. Recommend that the patient avoid alcohol, caffeine, and other stimulants, which may precipitate this condition. He is to contact me if his symptoms worsen, or he develops new symptoms.

BIVD IN SITU.
Normal device function per interrogation today.

HYPERTENSION.
No evidence of left ventricular hypertrophy per echocardiography. Recommend that the patient monitor his blood pressure twice daily and provide me with the records. Target systolic blood pressure in the 110-120 mmHg range recommended. Low salt, healthy diet advised.

DYSLIPIDEMIA.
Total cholesterol 171 mg/dL, HDL 25 mg/dL, triglycerides 405 mg/dL per labs on 07/03/16. LDL could not be calculated. Healthy diet advised.

CAROTID ARTERY DISEASE.
S/p left carotid endarterectomy. Non obstructive disease per carotid artery Duplex scan today.

H/O CVA.
The patient is back to his neurological baseline prior to CVA. Recommend follow up with a neurologist.

DILATED ASCENDING AORTA.
Mildly dilated ascending aorta 3.5 cm per echocardiography today. Optimal blood pressure and lipid profile recommended.

H/O PULMONARY EMBOLUS.
The patient was on Coumadin for a few years, and was recently switched to Eliquis.

ELEVATED D-DIMER.
D-Dimer 2.58 mcg/mL FEU per labs on 07/03/16. Will follow the patient carefully, and consider pulmonary CT angiography given a prior history of pulmonary embolus.

RENAL INSUFFICIENCY.
BUN 36 mg/dL, Creatinine 2.28 mg/dL, eGFR 27 per labs on 07/03/16. Recommend evaluation by a nephrologist.

AMIODARONE THERAPY.
Abnormal T3 levels, Low T3 per labs on 07/03/16. T4 and TSH levels within the normal range. LFTs within the normal range. Given his current symptoms, congestive heart failure, and shortness of breath, will consider discontinuing Amiodarone if he does not improve. Will follow with serial labs.

OTHER:
– HYPERURICEMIA. Uric acid 10.4 mg/dL per labs on 07/03/16. Will defer management to his internist.
– Benign prostatic hypertrophy. The patient is on Tamsulosin. He may benefit from switching to Uroxatral given orthostatic hypotension. Defer management to his urologist.
– Back pain/leg pain/lumbar disc disease. Defer management to his orthopedist.
– Constipation. Recommend increasing his fiber intake. Defer management to his gastroenterologist.

DISCUSSION:

PLAN:
Medication changes: No.

Procedures performed today: Carotid artery duplex scan, BiVD interrogation.

Diet: Patient advised to follow a healthy low fat, salt and carbohydrate diet.

Exercise recommendations: Regular exercise is strongly recommended. Recommend gradual increase in daily aerobic exercise.

Hypertension Instructions: The patient was instructed to monitor their blood pressure twice daily and provide me with the records.

Preventive Medicine: It is important that the patient follow up with their primary physician for preventative medicine follow ups including yearly prostate exam and annual physical exam.

Follow Up: The patient was advised to return to the office for follow up in 2 days or earlier if he has any medical problems.

Emergency recommendations: The patient was advised to call 911 or go to the emergency room if the patient’s condition worsens or does not improve.

——————————————————————————————————————————————————-
Changed/Discontinued Medication(s):
Discontinued By Other MD: CARVEDILOL 3.125 MG TABLET
Check in time: 09:36 AM Check out time: 11:14 AM

Electronically signed: 07/06/2016 03:24 PM BENZUR, URI

Uri M. Ben-Zur, M.D., F.A.C.C.
Interventional Cardiology / Invasive Electrophysiology

18200 Ventura Blvd
Tarzana, CA 91356
Phone (818) 986-0911 Fax (818) 986-9301
Date of visit: 07/05/2016
Reason for Visit:
Requesting Physician:
I had the opportunity to evaluate on the date stated above. I have reviewed the past medical history, symptoms and current therapy. In addition, I have examined the patient and based on my findings have provided my overall impression, outlining my treatment and plans in the summary below.

CHIEF COMPLAINT /HISTORY OF PRESENT ILLNESS:

is an extremely pleasant 82 year old female with a past medical history of hypertension, hyperlipidemia, hypothyroidism, rheumatic heart disease, and questionable history of non-sustained ventricular tachycardia with ventricular fibrillation (details unclear). The patient underwent pacemaker implantation on 07/12/2008 given symptomatic sinus bradycardia. She is accompanied today by her husband, Leonid.

The patient presents today for a pre-operative cardiac assessment. She is scheduled to undergo permanent pacemaker pulse generator replacement at Providence Tarzana Medical Center on 07/13/16, given that her battery is nearing ERI. She is planning to travel in the near future and wishes to have the procedure performed as soon as possible.

The patient complains of occasional palpitations, described as fast heartbeats. Each episode lasts for a few seconds and resolves spontaneously. No associated symptoms noted.

The patient denies any recent chest pain, shortness of breath, dizziness, syncope.

Her blood pressure readings have been within normal limits at home. Ms. PETRUZOVA is following an exercise program. She follows a healthy diet.

At the time of her last visit, no medication changes were made.

Overall, states that she is stable.
PAST MEDICAL HISTORY:
Cardiovascular:
Hyperlipidemia.
Hypertension, benign essential.
Symptomatic sinus bradycardia. Permanent pacemaker implant 07/2008.
History of non-sustained ventricular tachycardia with ventricular fibrillation (details unclear)
Rheumatic heart disease.
HEENT:
Benign Positional Vertigo.
Psychiatry:
Anxiety.
Endocrine:
Hypothyroidism.
SURGICAL HISTORY:
Cataract extraction and intraocular lens implant 01/25/16.
Permanent pacemaker implantation given sinus bradycardia 30s bpm, symptomatic with weakness on 07/11/2008
Appendectomy.

CURRENT MEDICATIONS:
1 Meclizine 25 Mg Tablet SIG: take one tablet daily as needed
2 Cozaar 100 Mg Tablet SIG: Take 1 tab by mouth once daily
3 Diltiazem Cd 180 Mg Capsule SIG: 1 DAILY
4 Levothyroxine 75 Mcg Tablet (Other MD) SIG: Take 1 tab PO QD
5 Norvasc 5 Mg Tablet (Other MD) SIG: Take 1 tab PO QD-BID
6 Paxil 20 Mg Tablet (Other MD) SIG: Take ½ tab PO QD

ALLERGIES / INTOLERANCES:
diltiazem

SOCIAL HISTORY:
Marital Status: The patient is married.
Smoking/tobacco use: No history of smoking.
Alcohol: Non alcoholic beverage drinker.
Recreational drug use: She denies recreational drug use.
Caffeine Intake: She does not drink coffee, tea, soda or any other caffeinated drinks and beverages.

FAMILY HISTORY:
Father deceased at 33 from wound in WWII
Mother deceased at 74 from CVA.
REVIEW OF SYSTEMS:
Constitutional Symptoms: (-) fever, (-) chills, (-) night sweats, (-) fatigue, (-) weakness, (-) changes in appetite or weight.

Integumentary: (-) rash, (-) lumps, (-) itching, (-) dryness, (-) acne, (-) discoloration, (-) recurrent skin infections, (-) changes in hair, nails or moles.

Respiratory: (-) cough, (-) hemoptysis, (-) cyanosis, (-) wheezing, (-) nocturnal choking or gasping.

Cardiovascular: (-) chest pain, (-) dizziness, (-) dyspnea with exertion, (-) edema, (-) high blood pressure, (-) irregular heartbeat, (-) orthopnea, (+) palpitations, (-) paroxysmal nocturnal dyspnea, (-) Syncope.
Cardiovascular: (+) palpitations.
Gastrointestinal: (-) abdominal pain, (-) heartburn, (-) constipation, (-) diarrhea, (-) nausea, (-) vomiting, (-) hematochezia, (-) melena, (-) change in bowel habits.

Genitourinary: (-) dysuria, (-) frequency, (-) urgency, (-) hesitancy, (-) polyuria, (-) nocturia, (-) hematuria, (-) urinary incontinence, (-) flank pain, (-) change in urinary habits.

Musculoskeletal: (-) muscle pain, (-) joint pain, (-) bone pain.

Peripheral Vascular: (-) intermittent claudication, (-) cramps, (-) varicose veins, (-) thrombophlebitis.

Neurological: (-) numbness, (-) tingling, (-) tremors, (-) seizures, (-) vertigo, (-) memory loss, (-) any focal or diffuse neurological deficits.

Endocrine: (-) heat or cold intolerance, (-) excessive sweating, (-) excessive thirst, (-) excessive hunger, (-) excessive urination, (-) hirsutism, (-) change in ring or shoe size.

Hematologic/Lymphatic: (-) anemia, (-) easy bruising, (-) excessive bleeding, (-) history of blood transfusions.

PHYSICAL EXAM:
Vitals:
BP: 125/78(Left Arm)(Supine)
Pulse: 78(Left brachial)(Standing)(Regular)

Height: 5′ 3″
BSA: 0
BP: 122/74(Left Arm)(Standing)
Pulse: 86(Left brachial)(Standing)(Regular)

General Appearance: The patient is an extremely pleasant 82 year old female who looks younger than her stated age. is well developed and well nourished in no apparent distress. Her body habitus is within normal limits. Her mood is normal.
HEENT: Normocephalic and atraumatic. Pupils are equally round and reactive to light and accommodation. Extraocular muscles are intact. Patient’s neck is supple with no jugular venous distention, no carotid bruit was heard and carotid pulses are +2/2. Normal carotid artery upstroke bilaterally. Palpation is not painful and no thyromegaly nor lymphadenopathy can be appreciated.
Respiratory: Clear to auscultation bilaterally without wheezes or rhonchi. No intercostal retractions or accessory muscle use were noted.
Cardiovascular: Regular heart rate and rhythm. Cardiac point of maximal impulse at left fifth intercostal space mid-clavicular line. Normal S1, S2 with physiologic splitting of S2. No murmurs, thrills, rubs, gallops, or clicks were heard. S/p permanent pacemaker implantation.
Gastroenterology: Abdomen is soft non-tender and non-distended. Positive bowel sounds, no hepatomegaly or splenomegaly was noted. No bruits were heard.
Extremities: Pulses were 2+ throughout bilaterally. No cyanosis, edema or clubbing.
Musculoskeletal: Motor strength is appropriately intact throughout bilaterally.
Neurologic: Patient is alert and oriented x3 with deep tendon reflexes appropriately intact throughout bilaterally, non-focal.
Psychiatric: Patient is conscious, cooperative, and well-oriented to time, place, and person. There are no mood swings or psychotic features. Patient’s insight is good. Memory and judgement are intact.
Skin: No skin rash, subcutaneous nodules, lesions or ulcers observed.
DIAGNOSTIC DATA:

ELECTROCARDIOGRAM: Date performed: Mar 1, 2016.
Indication: Occasional palpitations, pre-op evaluation, Occasional shortness of breath.
Interpretation: Rate: 70 bpm; Rhythm: A paced V sensed, left axis deviation and poor R wave progression.
Conclusion: Abnormal ECG.

2D COLOR DOPPLER ECHOCARDIOGRAPHY:
Date: Sep 17, 2015 Indication: Occasional palpitations, h/o atrial arrhythmias.

Findings:
Left atrium: Dimension: 2.8 cm. (Men: 3-4 cm/Women: 2.7-3.8 cm).
Left ventricle:
-LVIDd = 3.7 cm (Men:4.2-5.9 cm/Women: 3.9-5.3cm).
-LVIDs = 2.3 cm (2.0-4.1 cm).
-IVS = 0.9 cm (0.6-1.1 cm).
-LVPWd = 0.9 cm (0.6-1.1 cm).
Wall kinesis: There is E-A flow reversal suggestive of diastolic dysfunction.

Right atrium: Normal in size and shape and shows no signs of ASD, mass or thrombus.
Right ventricle: RVSP: 30 mmHg (15-25 mmHg). Increased right ventricular pressure.

Aortic valve: Mild aortic sclerosis. No stenosis.
Mitral valve: Mild regurgitation. Mild annular calcification is noted.
Tricuspid valve: Normal tricuspid valve.
Pulmonic valve: Normal pulmonic valve.
Aorta: Ascending aorta: 2.3 cm. ( 2.1-3.4 cm).

Left ventricle ejection fraction: 60 %.

Pericardium: No effusion or calcification.
Pacemaker/ICD lead: Pacemaker lead in right heart.

TREADMILL STRESS TEST/W STRESS ECHOCARDIOGRAPHY.
Date: Jul 21, 2013. Indication: Occasional shortness of breath, Abnormal EKG
Risk and benefits of exercise stress test including but not limited to myocardial infarction, vascular compromise and death were explained to Ms. PETRUZOVA in detail. The patient asked appropriate questions. All questions were answered. The patient wished to proceed and gave her informed consent.

Protocol: Standard Bruce protocol.

Procedure:
STAGE I (Min 0 to 2:50): Min: 2 . MPH: 1.7. Grade: 10 %. MET: 1-5. BP: 120/80, Pulse: 109, O2 Sat: 98.
STAGE II (Min 3 to 5:50): Min: 4 . MPH: 2.5. Grade: 12%. MET: 6-7. BP: 140/80, Pulse: 105, O2 Sat: 96.
STAGE III (Min 6 to 8:50): Min: 6 . MPH: 3.4. Grade: 14%. MET 8-10. BP: 145/80, Pulse: 144, O2 Sat: 95.
STAGE IV (Min 9 to 11:50): Min: 9 . MPH: 4.2. Grade 16%. MET: 10-12. BP: 160/80, Pulse: 136, O2 Sat: 95.

Results:
Maximal Predicted Heart Rate: 141 bpm.
Peak heart rate achieved: 108 bpm.
Maximal heart rate achieved: 76 % of predicted heart rate.
Average O2 saturation throughout the study: 95 %.
Total Minutes: 9.09.
Reason for stopping: Generalized fatigue.

Clinical response:
Peak exercise electrocardiogram revealed no significant ischemic changes and no significant arrhythmias.

Stress echocardiography:
Revealed normal left ventricular function at rest with an adequate increase in left ventricular function in response to exercise.

Findings:
Left atrium: Dimension: 3.1 cm. (Men: 3-4 cm/Women: 2.7-3.8 cm).
Left ventricle:
-LVIDd = 3.8 cm (Men:4.2-5.9 cm/Women: 3.9-5.3cm).
-LVIDs = 2.1 cm (2.0-4.1 cm).
-IVS = 1.1 cm (0.6-1.1 cm).
-LVPWd = 1 cm (0.6-1.1 cm).

Right atrium: Normal in size and shape and shows no signs of ASD, mass or thrombus.
Right ventricle: Normal in size and shape and shows no signs of VSD, mass or thrombus.

Aortic valve: Mild aortic sclerosis. No stenosis.
Mitral valve: Normal mitral valve without prolapse.
Tricuspid valve: Normal tricuspid valve.
Pulmonic valve: Normal pulmonic valve.
Aorta: No evidence of dissection, coarctation or aneurysm of the aorta.

Left ventricle ejection fraction: 60 %.

Pericardium: No effusion or calcification.

Summary: The patient exercised according to the BRUCE protocol for a total of 9.09 minutes, achieving a peak heart rate of 108 bpm, 76% of the maximum predicted heart rate. Electrocardiogram showed no significant ST-T changes. Atrial premature contractions/ventricular premature contractions/dysrhythmias were not seen.
Symptoms at peak exercise: generalized fatigue.
The study was inconclusive.

Conclusion:
Response to exercise: Stress testing performed today was inconclusive given that the maximal target heart rate was not achieved.
There is no evidence of inducible ischemia at the level of exercise achieved.
No evidence of stress induced arrhythmias at the level of exercise achieved.
The patient had an inadequate exercise capacity.
Interval changes: No interval changes.

Recommendations: Recommend increasing exercise program and repeat stress test in 3-6 months.

Holter Monitoring 24hrs: Hookup Date: Jul 29, 2010..
Indication: evaluation of palpitations.
Findings:
Normal Sinus rhythm. sinus.
Occasional Premature Ventricular Contractions, Occasional V paced with capture.

LOWER EXTREMITIES VENOUS DOPPLER: Sep 3, 2013.
Indication: Trace to +1 Bilateral leg edema.
Impression: Normal venous flow with normal collapse with compression. Normal augmentation of venous flow with calf compression. No evidence of venous insufficiency with valsalva manuever or abdominal pressure. Normal lower extremities.
No evidence of deep venous thrombosis or venous outflow obstruction of the lower extremities by duplex scanning.
ABDOMINAL AORTA DUPLEX SCAN:
Date: May 29, 2011 Indication: Indication: Hypertensive heart disease, controlled, w/o heart failure.

Aorta:
Proximal Aortic Diameter: 2.1 cm.
Proximal Aortic Peak Systolic Velocity: 0.83 m/s.
Mid Aortic Diameter: 1.4 cm.
Mid Aortic Peak Systolic Velocity: 0.83 m/s.
Distal Aortic Diameter: 1.2 cm.
Distal Aortic Peak Systolic Velocity: 0.49 m/s.

Technical impression: Abnormal study. plaque.

Plan: Minimal plaque seen in Abdominal Aorta.

PACEMAKER INTERROGATION REPORT: Date of Interrogation: Jul 5, 2016.
Implant Indication: Sick Sinus Syndrome.
Implant date: 07/12/2008.
Model: Biotronik Philos II DR-T.
Battery status: 2.63 V.
Estimated battery life: less than 2 months.

Atrial sensitivity: 3 mV.
Atrial threshold: 1 V at 0.4 ms.
Atrial impedance: 510 Ohms.

Right Ventricular sensitivity: 14 mV.
Right Ventricular threshold: 0.8 V at 0.4 ms.
Right Ventricular impedance: 650 Ohms.

Atrial Pacing: 52 %.
Ventricular pacing: 18 %.
Mode switching episodes: Atrial high rate:
6 Episode(s). Fastest atrial rate: 163 bpm.

Final Parameters:
Mode: DDD.
Lower rate: 60 bpm.

Interrogation Assessment: BATTERY NEARING ERI.
Normal device function, <2 months until ERI.

Carotid artery duplex scan Date: 7/28/2008. Indication: Dizziness.
RIGHT
Right External Carotid Artery Velocity: 101 cm/s
Right Distal Internal Carotid Artery Velocity: 85 cm/s
Right Distal Common Carotid Artery Velocity: 68 cm/s
Right Internal Carotid Artery/Common Carotid Artery Ratio: 1.3
Right vertebral artery flow is antegrade.
LEFT
Left External Carotid Artery Velocity: 95 cm/s
Left Distal Internal Carotid Artery Velocity: 94 cm/s
Left Distal Common Carotid Artery Velocity: 60 cm/s
Left Internal Carotid Artery/Left Common Carotid Artery Ratio: 1.6
Left vertebral artery flow is antegrade.
Impression RIGHT: RT Bulb plaque <10%, RT ICA plaque <20%
Impression LEFT: Mild intimal thickening in LT CCA, mild intimal thickening in LT Bulb, LT ICA plaque <10%
Plan: Non-obstructive disease and will intensify medical therapy.

RENAL ARTERY DUPLEX WITH RENAL SIZE & ABDOMINAL AORTA 10/17/2008
Indication: Uncontrolled hypertensive heart disease without heart failure
Peak Systolic Velocity, m/s
Right Renal Left Renal
Proximal Peak Systolic Velocity m/s (<1) .49 .68
Mid Peak Systolic Velocity m/s (<1) .72 .58
Distal Peak Systolic Velocity m/s (<1) .53 .41
Renal Aortic Ratio (<3.5) 1.6 1.5
Renal Length cm (8.5-15) 10.1 10.2
Cortical Thickness cm (>1.1) 1.1 1.3
Parenchymal Flow: ESP present Upper (Yes) Yes Yes
Parenchymal Flow: ESP present Mid (Yes) Yes Yes
Parenchymal Flow: ESP present Lower (Yes) Yes Yes
Resistive index (PSV-EDV/PSV) (<0.70) .62 .61

Duplex Scan of Abdominal Aorta: Date performed: 10/17/2008
Proximal Aortic Diameter 2.2 cm
Mid Aortic Diameter 1.7 cm
Distal Aortic Diameter 1.2 cm
Aortic Peak Systolic Velocity.46 m/s
Impression: Normal study and Plaque
Additional findings: Mild plaque seen in abdominal aorta (proximal to distal).
Kidney Ultrasound: Date performed: 10/17/2008
Technique: Using real-time ultrasound and a high-resolution probe, multiple transverse and longitudinal images of both kidneys were obtained.
Findings: Bilateral kidneys appeared normal in size and echogenicity. Right kidney measures 10.1 cm x 4.0 cm x 4.8 cm. Left kidney measures 10.2 cm x 4.8 cm x 4.5 cm. No definite solid masses or hydronephrosis are identified. No free fluid is seen.
Technical Impression: Within normal limits

Lower Extremity Artery Duplex 04/24/09
Indication: Lower extremity edema, +1 right, trace left and after prolonged travel
Criteria for stenosis:
% Stenosis — Velocity Ratio
Normal <1.5:1
30% – 49% –> 1.5: 1-2: 1
50% – 75% –> 2: 1-4: 1
>75% is >4:1
Occlusion –> No color Saturation
Normal Range Artery Velocity:
Artery — Velocity (m/sec)
External Iliac 97.6-141
Common Femoral 89.2-139
Superficial Femoral (proximal) 77.2-104.4
Superficial Femoral (distal) 79.5-107.7
Popliteal 55.3-82.3
Technical Impression: Within normal limits and No Evidence of Arterial Stenosis
Comments: Negative DVT.
Last cervical / vaginal PAP smear: 08/2008, was normal per patient.
Last mammogram: 09/10/2008 cyst was found, no malignancies, ultrasound showed no abnormalities. Followed by Dr. Hoffman.
Pneumovax vaccine 07/2008 and Influenza vaccine 07/2008.
FLU VACCINATION: DECLINES.
Patient’s Physicians:
Internist/Primary physician: Dr. Kleynberg.

————————————————————————————————————————————————————
DIAGNOSIS/ASSESSMENT:

H/O SYMPTOMATIC BRADYCARDIA.
CARDIAC PACEMAKER IN SITU.
S/p permanent pacemaker implantation on 07/12/2008 for symptomatic sinus bradycardia with severe dizziness and fatigue. Normal device function per interrogation today. Battery nearing depletion. She is scheduled to undergo pacemaker pulse generator replacement on 07/13/16.

PRE-PROCEDURE CARDIAC ASSESSMENT.
The patient is optimized from a cardiovascular standpoint for pacemaker pulse generator replacement at Providence Tarzana Medical Center on 07/13/16. I had a long discussion with the patient regarding the risks, benefits, and alternatives to the procedure, including but not limited to infection, bleeding, heart attack, stroke, death, complications associated with anesthesia, and possible drug allergies.The patient was asked to repeat to me that anything can happen during a surgical procedure and that there is a possibility of death or severe disability as a result of the procedure. The patient was able to do so without any difficulty.

PALPITATIONS.
Minimally symptomatic. EKG showed A paced with A capture, left axis deviation, and poor R wave progression. Echocardiography showed normal left atrial dimensions, no evidence of mitral valve prolapse. Continue Diltiazem. Recommend that the patient avoid stress, alcohol, caffeine, and other stimulants, which may precipitate this condition. She is to contact me if this symptom worsens, or she develops new symptoms.

H/O SINUS TACHYCARDIA/ PAROXYSMAL ATRIAL FLUTTER/ATRIAL TACHYCARDIA
No recurrence noted on device interrogation today. Continue Diltiazem.

HYPERTENSION, BENIGN, ESSENTIAL.
No evidence of left ventricular hypertrophy per echocardiography. Recommend that the patient monitor her blood pressure twice daily and provide me with the records. Target systolic blood pressure in the 110-120 mmHg range recommended. Low salt diet advised.

HYPERLIPIDEMIA.
Total chol 203 mg/dL, LDL 118 mg/dL, HDL 73 mg/dL on 12/22/15. The patient was advised to increase daily exercise and follow a low fat diet. Defer management to Dr. Kleynberg.

HYPOTHYROIDISM.
TSH 2.25 mIU/L per labs on 12/22/15. The patient is on Levothyroxine. Defer management to Dr. Kleynberg.

DISCUSSION:

PLAN:
Medication changes: No.

Laboratory: Lipid panel, Chem 24, CBC, TSH.

Procedures performed today: Pacemaker complete interrogation.

Diet: Patient advised to follow a healthy low fat, salt and carbohydrate diet.

Exercise recommendations: Regular exercise is strongly recommended.

Hypertension Instructions: The patient was instructed to monitor their blood pressure twice daily and provide me with the records.

Follow Up: The patient was advised to return to the office for follow up in 2 months or earlier if she has any medical problems.

Emergency recommendations: The patient was advised to call 911 or go to the emergency room if the patient’s condition worsens or does not improve.

ROUTINE FOLLOW-UP WITH PATIENT’S PRIMARY PHYSICIAN, Dr. KLEYNBERG, ADVISED.

——————————————————————————————————————————————————-

Check in time: 09:39 AM Check out time: 11:14 AM

Electronically signed: 07/06/2016 10:57 AM BENZUR, URI

99215 Office/outpatient visit, est, high; G8427 Med.with dosage and verification documented; 1036F CURRENT TOBACCO NON-USER CAD CAP COPD PV DM; G8419 BMI abnormal. No followup plan documented; 93280 Analyze/reprogram pacemaker system/Dual

Uri M. Ben-Zur, M.D., F.A.C.C.
Interventional Cardiology / Invasive Electrophysiology

18200 Ventura Blvd
Tarzana, CA 91356
Phone (818) 986-0911 Fax (818) 986-9301
Date of visit: 07/05/2016
Reason for Visit:
Requesting Physician:
I had the opportunity to evaluate on the date stated above. I have reviewed the past medical history, symptoms and current therapy. In addition, I have examined the patient and based on my findings have provided my overall impression, outlining my treatment and plans in the summary below.

CHIEF COMPLAINT /HISTORY OF PRESENT ILLNESS:

is an extremely pleasant 79 year old male with a past medical history of coronary artery disease, status post myocardial infarction in 1999, non-sustained ventricular tachycardia, pulmonary embolism in 08/2007, diabetes mellitus, hyperlipidemia, hypertension, and asthma. He is on chronic anticoagulation therapy and is followed by Dr. Kleynberg.

The patient is being followed closely given a recent history of worsening shortness of breath/leg edema. This symptoms have now improved with medication adjustments.

The patient denies chest pain, palpitations, dizziness, syncope. His blood sugar levels range from 100 to 130 mg/dL according to his home monitor. The patient does not follow an exercise program. He does not follow a specific diet.

The patient is on chronic anticoagulation therapy. He monitors his INR at home every Wednesday and his Coumadin dose is adjusted by Dr. Kleynberg.

Overall, states that he has been improving.
PAST MEDICAL HISTORY:
Cardiovascular:
Coronary Artery Disease. Status post myocardial infarction in 1999.
Hyperlipidemia.
Hypertension, benign essential.
Non-sustained ventricular tachycardia post stress testing on 07/28/2008
Pulmonary embolism in August 2007.
Respiratory:
Asthma.
Bronchiectasis.
Chronic Obstructive Pulmonary Disease.
Gastroenterology:
Peptic Ulcer Disease. H/o bleeding ulcer.
Genitourinary:
Benign Prostatic Hyperplasia.
H/o prostate adenoma.
Endocrine:
Diabetes mellitus.
Skin:
Psoriasis, managed by dermatology.
SURGICAL HISTORY:
Balloon angioplasty x 4, 1999 x2, 2000, 2001. Awaiting medical records
S/P coronary angiogram, 07/29/2008
Hernia repair x 3
Prostate adenoma resection, 1984
S/P Appendectomy.

CURRENT MEDICATIONS:
1 Aricept 5 Mg Tablet SIG: Take 1 tab by mouth once daily
2 Seroquel 50 Mg Tablet SIG: one PO QD
3 Omeprazole Dr 20 Mg Capsule SIG: Take 1 pill BID
4 Pulmicort 0.5 Mg/2 Ml Respule SIG: BID
5 Spiriva 18 Mcg Cp-handihaler SIG: Take 1 CAP daily
6 Crestor 5 Mg Tablet SIG: Take 1 tab by mouth once daily
7 Flovent Hfa 220 Mcg Inhaler Mcg/actuation SIG: 2 puffs twice daily
8 Potassium Cl Er 20 Meq Tablet SIG: take one PO QD
9 Amiloride Hcl 5 Mg Tablet SIG: Take 1 daily
10 Hyzaar 100-25 Tablet Mg SIG: PO QD
11 Lasix 40 Mg Tablet SIG: one tab PO BID
12 Otezla 30 Mg SIG: One tablet PO BID
13 Cosentyx
14 Primidone 375 Mg Tablet (Other MD) SIG: 1 daily
15 Xopenex Hfa 45 Mcg Inhaler Mcg/actuation (Other MD) SIG: 2 puffs BID
16 Coumadin (Other MD) SIG: 5/7.5 mg alt PO QD

ALLERGIES / INTOLERANCES:
spironolactone, Statins-Hmg-Coa Reductase Inhibitors

SOCIAL HISTORY:
Marital Status: The patient is married, with 3 children.
Smoking/tobacco use: Discontinued 1984. Total of 42 Pack Years.
Alcohol: The patient rarely drinks alcoholic beverages.
Recreational drug use: He denies recreational drug use.
Caffeine Intake: 1 cup of coffee/day.
Occupation: Retired surgeon.

FAMILY HISTORY:
Mother. Deceased at 82. History of hypertension, acute leukemia
Father. deceased at 83. History of colon cancer, hypertension.
REVIEW OF SYSTEMS:
Constitutional Symptoms: (-) fever, (-) chills, (-) night sweats, (-) fatigue, (-) weakness, (-) changes in appetite or weight.

Integumentary: (-) rash, (-) lumps, (-) itching, (-) dryness, (-) acne, (-) discoloration, (-) recurrent skin infections, (-) changes in hair, nails or moles.

Head: (-) headaches, (-) head injury or deformity, (-) visual changes, (-) eye pain, (-) double or blurred vision, (-) hearing changes, (-) tinnitus, (-) vertigo, (-) use of hearing aids, (-) frequent colds, (-) nasal allergies. Ears, Nose, Mouth, Throat: (-) hearing changes, (-) tinnitus, (-) vertigo, (-) dizziness, (-) earache, (-) ear infection, (-) ear discharge, (-) use of hearing aids. Neck: (-) swollen glands, (-) enlarged thyroid, (-) neck pain.

Respiratory: (-) cough, (-) hemoptysis, (-) cyanosis, (-) wheezing, (-) nocturnal choking or gasping.

Cardiovascular: (-) chest pain, (-) dizziness, (+) dyspnea with exertion, (+) edema, (-) high blood pressure, (-) palpitations, (-) Syncope.
Cardiovascular: (+) dyspnea with exertion, (+) edema.
Gastrointestinal: (-) abdominal pain, (-) heartburn, (-) constipation, (-) diarrhea, (-) nausea, (-) vomiting, (-) hematochezia, (-) melena, (-) change in bowel habits.

Genitourinary: (-) dysuria, (-) frequency, (-) urgency, (-) hesitancy, (-) polyuria, (-) nocturia, (-) hematuria, (-) urinary incontinence, (-) flank pain, (-) change in urinary habits.

Musculoskeletal: (-) muscle pain, (-) joint pain, (-) bone pain.

Peripheral Vascular: (-) intermittent claudication, (-) cramps, (-) varicose veins, (-) thrombophlebitis.

Neurological: (-) numbness, (-) tingling, (-) tremors, (-) seizures, (-) vertigo, (-) memory loss, (-) any focal or diffuse neurological deficits.

Endocrine: (-) heat or cold intolerance, (-) excessive sweating, (-) excessive thirst, (-) excessive hunger, (-) excessive urination, (-) hirsutism, (-) change in ring or shoe size.

Hematologic/Lymphatic: (-) anemia, (-) easy bruising, (-) excessive bleeding, (-) history of blood transfusions.

PHYSICAL EXAM:
Vitals:
BP: 110/72(Left Arm)(Standing)
Pulse: 87(Left brachial)(Standing)

Weight: 230 lbs
Height: 5′ 3″
BMI: 40.74
BSA: 2.15
BP: 112/75(Left Arm)(Supine)
Pulse: 82(Left brachial)(Supine)(Regular)
Oxygen: 95(Room air)

General Appearance: The patient is an extremely pleasant 79 year old male who looks younger than his stated age. is well developed and well nourished in no apparent distress. His body habitus is morbidly obese, his mood is normal.
HEENT: Normocephalic and atraumatic. Pupils are equally round and reactive to light and accommodation. Extraocular muscles are intact. Patient’s neck is supple with no jugular venous distention, left carotid bruit heard and carotid pulses are +2/2. Normal carotid artery upstroke bilaterally. Palpation is not painful and no thyromegaly nor lymphadenopathy can be appreciated.
Respiratory: Clear to auscultation bilaterally without wheezes or rhonchi. No intercostal retractions or accessory muscle use were noted.
Cardiovascular: Regular heart rate and rhythm. Cardiac point of maximal impulse at left fifth intercostal space mid-clavicular line. Normal S1, S2 with physiologic splitting of S2. No murmurs, thrills, rubs, gallops, or clicks were heard.
Gastroenterology: Abdomen is soft non-tender and non-distended. Positive bowel sounds, no hepatomegaly or splenomegaly was noted. Abdominal bruit heard.
Extremities: Pulses were 2+ throughout bilaterally. No cyanosis or clubbing. 2+ bilateral leg edema.
Musculoskeletal: Motor strength is appropriately intact throughout bilaterally.
Neurologic: Patient is alert and oriented x3 with deep tendon reflexes appropriately intact throughout bilaterally, non-focal. Involuntary tremors/right hand coarse tremor.
Psychiatric: Patient is conscious, cooperative, and well-oriented to time, place, and person. There are no mood swings or psychotic features. Patient’s insight is good. Memory and judgement are intact.
Skin: No skin rash, subcutaneous nodules, lesions or ulcers observed.
DIAGNOSTIC DATA:

Encounter long term anticoagulant. Date: Jul 5, 2016.
INR: 3, out-house.
Current Dose: : 7.5/5 mg PO QD alternating dose.
Therapeutic Goal/INR: 2.0 – 3.0 per Dr. Kleynberg.

ELECTROCARDIOGRAM: Date performed: Dec 22, 2015.
Indication: Recurrent shortness of breath.
Interpretation: Rate: 77 bpm; Rhythm: Normal sinus rhythm and S/P Inferior Wall Myocardial Infarction, age is undetermined; Axis: Left axis deviation.
Conclusion: Abnormal ECG.

2D COLOR DOPPLER ECHOCARDIOGRAPHY:
Date: Dec 22, 2015 Indication: Recurrent shortness of breath, Abnormal EKG, S/P possible MI.

Findings:
Left atrium: Dimension: 3.8 cm. (Men: 3-4 cm/Women: 2.7-3.8 cm).
Left ventricle:
-IVS = 0.9 cm (0.6-1.1 cm).
-LVPWd = 0.9 cm (0.6-1.1 cm).

Right atrium: Normal in size and shape and shows no signs of ASD, mass or thrombus.
Right ventricle: RVSP: 39 mmHg (15-25 mmHg).

Aortic valve: Normal trileaflet aortic valve.
Mitral valve: Normal mitral valve without prolapse.
Tricuspid valve: Trace regurgitation. No sclerosis. No stenosis. No vegetations noted.
Pulmonic valve: Normal pulmonic valve.
Aorta: No evidence of dissection, coarctation or aneurysm of the aorta.

Left ventricle ejection fraction: 60 %.

Pericardium: No effusion or calcification.
Venous: Inferior vena cava: Normal diameter with normal respiratory variation.

TREADMILL STRESS TEST/W STRESS ECHOCARDIOGRAPHY.
Date: Jun 5, 2011. Indication: Occasional shortness of breath, History of severe CAD, s/p PCI
Risk and benefits of exercise stress test including but not limited to myocardial infarction, vascular compromise and death were explained to Mr. BARGMAN in detail. The patient asked appropriate questions. All questions were answered. The patient wished to proceed and gave his informed consent.

Procedure:
STAGE I (Min 0 to 2:50): Min: 3 . MPH: 1.7. Grade: 10 %. MET: 1-5. BP: 140/80, Pulse: 109, O2 Sat: 96.
STAGE III (Min 6 to 8:50): Min: 8 . MPH: 3.4. Grade: 14%. MET 8-10. BP: 150/80, Pulse: 129.

Results:
Maximal Predicted Heart Rate: 146 bpm.
Peak heart rate achieved: 131 bpm.
Maximal heart rate achieved: 89 % of predicted heart rate.
Average O2 saturation throughout the study: 96 %.
Total Minutes: 9.
Reason for stopping: Generalized fatigue.

Clinical response:
Peak exercise electrocardiogram demonstrated no significant ischemic changes nor arrhythmias.

Stress echocardiography:

Findings:
1. Normal right heart size and function
2. Left heart size dimensions are normal.
3. Left ventricular ejection fraction is normal at 60%.
4. Global systolic function normal.
5. Normal valvular structure.
6. No pericardial effusion.

Summary: The patient exercised according to the BRUCE protocol 9 achieving a peak heart rate of 131 bpm, 89% of the maximum predicted heart rate. Electrocardiogram showed no significant ST-T changes. Atrial premature contractions/ventricular premature contractions/dysrhythmias were not seen.
Blood pressure response to exercise was normal at 150/80 mmHg.
Symptoms at peak exercise: generalized fatigue.
The study revealed an adequate cardiovascular exercise stress test with a normal hemodynamic response to exercise.

Conclusion:
There is no evidence of inducible ischemia at the level of exercise achieved.
No evidence of stress induced arrhythmias at the level of exercise achieved.
The patient had an adequate exercise capacity.
Probability of obstructive coronary artery disease: Low. It was discussed with the patient that coronary artery disease may be present despite the results of the exercise stress test. Exercise stress testing is only one diagnostic tool and is related to statistical and “pre-test probability”. It may be falsely negative in the presence of significant coronary artery disease. Other diagnostic tests may be in order if new symptoms develop or if symptoms recur or change in quality or duration. The patient was instructed to contact me immediately and contact emergency medical services in this event.

CAROTID ARTERY DUPLEX SCAN:
Date of Study: Jun 5, 2016.
Indication: Left carotid bruit.

Measurements:
Left:
CCA distal peak velocity: 65 cm/sec.
CCA end diastolic velocity: 16 cm/sec.
ICA distal peak velocity: 72 cm/sec.
ICA end diastolic velocity: 23 cm/sec.
ECA distal peak velocity: 92 cm/sec.
ECA end diastolic velocity: 16 cm/sec.
Left vertebral artery showed antegrade flow.
ICA/CCA: 1.1.
Right:
CCA distal peak velocity: 82 cm/sec.
CCA end diastolic velocity: 19 cm/sec.
ICA distal peak velocity: 48 cm/sec.
ICA end diastolic velocity: 20 cm/sec.
ECA distal peak velocity: 65 cm/sec.
ECA end diastolic velocity: 12 cm/sec.
Right vertebral artery showed antegrade flow.
ICA/CCA: 0.6.

Impression/Comments:
Left:
Left bulb plaque: Less than 10%.
Left ECA: Less than 10%.
Right:
Right ICA: Less than 10%.
Right ECA: Less than 10%.

Plan:
Non-obstructive disease.
Will intensify medical therapy.

LOWER EXTREMITIES VENOUS DOPPLER: Feb 5, 2013.
Indication: Occasional shortness of breath, +1 Bilateral leg edema.
Impression: Normal venous flow with normal collapse with compression. Normal augmentation of venous flow with calf compression. No evidence of venous insufficiency with valsalva manuever or abdominal pressure. Normal lower extremities.
No evidence of deep venous thrombosis or venous outflow obstruction of the lower extremities by duplex scanning.

RENAL ARTERY-AORTA DUPLEX SCAN: Jul 14, 2015.
Indication: Uncontrolled hypertensive heart disease without heart failure (402.00).

Measurements:
Left Renal Peak Systolic Velocity:
Proximal: 0.61 m/s [<1.0].
Mid: 0.5 m/s [<1.0].
Distal: 0.41 m/s [<1.0].
Renal/Aortic Ratio: 0.9. [<3.5].
Right Renal Peak Systolic Velocity:
Proximal: 0.8 m/s [<1.0].
Mid: 0.49 m/s [<1.0].
Distal: 0.51 m/s [<1.0].
Renal/Aortic Ratio: 1.2. [<3.5].

Aorta:
Proximal Aortic Diameter: 2.2 cm.
Mid Aortic Diameter: 1.7 cm.
Distal Aortic Diameter: 1.4 cm.
Aortic Peak Systolic Velocity: 0.65 m/s.

Kidney:
Left:
kidney length: 11.5 cm [8.5-15.0 cm].
Kidney Width: 5.5 cm. ( 4.5-5.0 cm].
Kidney Depth (trans): 4.5 cm. [4.5-5.0].
Cortical Thickness: 1.4 cm. [1.1 cm].
Parenchymal Flow /Waveform:
Upper Early Systolic Peak Present.
Mid Early Systolic Peak Present.
Lower Early Systolic Peak Present.
Resistive Index: 0.66 [<0.75] (PSV-EDV/PSV).

Right:
kidney length: 12.2 cm [8.5-15.0 cm].
Kidney Width: 5.3 cm. ( 4.5-5.0 cm].
Kidney Depth (trans): 5.5 cm. [4.5-5.0].
Cortical Thickness: 1.8 cm. [1.1 cm].
Parenchymal Flow /Waveform:
Upper Early Systolic Peak Present.
Mid Early Systolic Peak Present.
Lower Early Systolic Peak Present.
Resistive Index: 0.72 [<0.75]
(PSV-EDV/PSV).

Technical impression: Abnormal study. (1) Simple cyst seen in the left kidney measuring 2.0cm x 1.8cm x 1.9cm.
No change compared with previous study.

ABDOMINAL AORTA DUPLEX SCAN:
Date: Sep 15, 2014 Indication: Indication: Hypertension (401.1) and abdominal bruit.

Aorta:
Proximal Aortic Diameter: 2.2 cm.
Proximal Aortic Peak Systolic Velocity: 0.75 m/s.
Mid Aortic Diameter: 1.6 cm.
Mid Aortic Peak Systolic Velocity: 0.81 m/s.
Distal Aortic Diameter: 1.3 cm.
Distal Aortic Peak Systolic Velocity: 0.64 m/s.

Technical impression:
Within normal limits. Mild plaque seen in abdominal aorta.
Technically difficult study due to patient’s body habitus.

Other:
Coronary angiogram performed on 7/29/2008, indication: recurrent episodes of chest pain post MI and nonsustained ventricular tachycardia post stress testing. Revealed: Left main was nonobstructive. Left anterior descending was not obstructed. The diagonal vessel had approximately 40-50% stenosis. The circumflex artery is dominant and nonobstructive. Right coronary artery is nondominant. LVEDP measured 24 mmHg. No significant mitral regurgitation. EF 50-52%.

CORONARY ANGIOGRAPHY performed on 01/21/1999 showed: 1. Recent large anterior myocardial infarction associated with left ventricular failure. 2. Considerable dissolution of the clot in the proximal left anterior descending coronary artery with residual small clot. 3. Mild hypokinesis of the anterior left ventricular wall.

CORONARY ANGIOGRAPHY performed on 07/19/2001 showed: left main patent, severe heavy plaques and beading in the LAD after the first diagonal, circumflex artery was large, dominant, and free of significant disease, right coronary artery was very small and had 40-50% ostial stenosis. Final diagnosis: Stable coronary artery disease with a small ostial lesion in the right coronary artery which has appeared since the angiography of two years ago.

ULTRASOUND OF THE LIVER & GALLBLADDER
Date: 09/03/2013
Indication: Increased LFT’s
Impression: Study within normal limits.

RENAL ARTERY DUPLEX WITH RENAL SIZE & ABDOMINAL AORTA 8/1/2008
Indication: Atherosclerosis of other specified arteries
Peak Systolic Velocity, m/s
Right Renal Left Renal
Proximal Peak Systolic Velocity m/s (<1) .36 .76
Mid Peak Systolic Velocity m/s (<1) .77 .74
Distal Peak Systolic Velocity m/s (<1) .46 .65
Renal Aortic Ratio (<3.5) 1.7 1.7
Renal Length cm (8.5-15) 10.0 10.4
Cortical Thickness cm (>1.1) 1.1 1.0
Parenchymal Flow: ESP present Upper (Yes) Yes Yes
Parenchymal Flow: ESP present Mid (Yes) Yes Yes
Parenchymal Flow: ESP present Lower (Yes) Yes Yes
Resistive index (PSV-EDV/PSV) (<0.70) .71 .68

Duplex Scan of Abdominal Aorta: Date performed: 8/1/2008
Proximal Aortic Diameter 2.0 cm
Mid Aortic Diameter 1.7 cm
Distal Aortic Diameter 1.3 cm
Aortic Peak Systolic Velocity.46 m/s
Impression: Plaque
Additional findings: Mild plaque in Aorta (proximal to distal).

Kidney Ultrasound: Date performed: 8/1/2008
Technique: Using real-time ultrasound and a high-resolution probe, multiple transverse and longitudinal images of both kidneys were obtained.
Findings: Bilateral kidneys appeared normal in size and echogenicity. Right kidney measures 10.0 cm x 4.8 cm x 6.5 cm. Left kidney measures 10.4 cm x 4.8 cm x 5.0 cm. No definite solid masses or hydronephrosis are identified. No free fluid is seen.

Technical Impression: Abnormal Study
Comments: (1) small simple cyst in left kidney measuring 2.0cm x 1.8cm x 1.7cm.

Lower Extremity Artery Duplex 10/30/2008
Indication: pain in limb and +1 bilateral leg edema
Criteria for stenosis:
% Stenosis — Velocity Ratio
Normal <1.5:1
30% – 49% –> 1.5: 1-2: 1
50% – 75% –> 2: 1-4: 1
>75% is >4:1
Occlusion –> No color Saturation
Normal Range Artery Velocity:
Artery — Velocity (m/sec)
External Iliac 97.6-141
Common Femoral 89.2-139
Superficial Femoral (proximal) 77.2-104.4
Superficial Femoral (distal) 79.5-107.7
Popliteal 55.3-82.3

Right Side m/s Waveform (RT) Comment (RT) Left Side m/s Waveform (LT) Comment (LT)
Iliac
Common Femoral .96 triphasic 1.03 triphasic calcified plaque <20%
Profunda Femoris .46 triphasic mild intimal thickening .66 triphasic
Superficial Femoral (proximal) .62 triphasic .71 triphasic
Superficial Femoral (mid) .62 triphasic plaque <10% .77 triphasic
Superficial Femoral (distal) .64 triphasic plaque <10% .78 triphasic plaque <20%
Popliteal .51 triphasic .53 triphasic plaque <20%
Posterior Tibial
Anterior Tibia
Dorsalis Pedis

Technical Impression: Within normal limits
Comments: Non-obstructive disease. Intensify medical therapy.

Last colonoscopy: 2005. Benign polyp and diverticulosis per patient.
Last prostate exam / urological evaluation: 02/2009; benign prostatic hyperplasia, per patient- PSA 2.04 mg/ml as of 05/31/11.
FLU VACCINATION: Sep 17, 2015.
Patient’s Physicians:
Internist/Primary physician: Dr. Kleynberg.

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DIAGNOSIS/ASSESSMENT:

COMPLEX PATIENT.

SHORTNESS OF BREATH/ORTHOPNEA/LEG EDEMA.
CONGESTIVE HEART FAILURE NYHA CLASS II-III.
EKG showed normal sinus rhythm and left axis deviation. Echocardiography revealed mildly increased pulmonary pressures, normal left ventricular function, with EF 60%. Coronary angiogram in 2008 revealed non-obstructive coronary arteries. Recommend further evaluation to assess his coronary arteries. The patient declines for now. He is aware of the risks of doing so. The patient was advised of the importance of cardiac risk factor modification, including optimal blood pressure, blood sugar, lipid profile, a healthy diet, and aerobic exercise as tolerated. The patient is to proceed immediately to the nearest ER if these symptoms worsen, or he develops new symptoms. Stat dose of Lasix 20mg PO given in the office.

LEFT CAROTID BRUIT.
Non-obstructive disease on carotid artery Duplex scan.

CORONARY ARTERY DISEASE.
S/p multiple balloon angioplasties. Coronary angiogram performed on 7/29/2008 revealed non-obstructive disease. HIGH RISK PATIENT. The patient absolutely declines any further diagnostic testing. Recommend follow up with Dr. Kleynberg.

HISTORY OF RECURRENT PULMONARY EMBOLI.
08/2007. The patient is on chronic anticoagulation therapy. His Coumadin dose is adjusted by Dr. Kleynberg.

HYPERTENSIVE HEART DISEASE.
Controlled. No evidence of left ventricular hypertrophy, renal artery stenosis or abdominal aortic aneurysm per diagnostic studies. Recommend that the patient continue to monitor his blood pressure twice daily and provide me with the records. Target systolic blood pressure in the 110-120 mmHg range recommended. A low salt diet is advised.

DIABETES MELLITUS, TYPE II.
Defer management to Dr. Kleynberg.

DYSLIPIDEMIA.
LDL 82 mg/dL, HDL 45 mg/dL, TG 157 mg/dL on 05/29/16. Followed by Dr. Kleynberg.

HYPERURICEMIA.
Uric acid 9.2 mg/dL per labs on 06/05/16. Low purine diet recommended. Defer management to his internist.

RENAL INSUFFICIENCY.
BUN 30 mg/dL, Creatinine 1.38 mg/dL, eGFR 48 per labs on 06/05/16. Defer management to his internist.

H/O ELEVATED LIVER FUNCTION TESTS.
Resolved. Will follow with serial labs.

OTHER:
– History of non-sustained ventricular tachycardia. No recurrence. No exercise induced arrhythmias per stress test 06/05/11.
– History of peptic ulcer disease, s/p upper GI bleed. Defer to Dr. Jacobs.
– History of prostate adenoma s/p resection, 1984. Benign Prostatic hyperplasia. The patient declines prostate biopsy. Defer management to his urologist.
– Small simple cyst in the left kidney based on renal ultrasound. Stable. Defer management to Dr. Kleynberg.
– Hand tremor. The patient self-discontinued Carbidopa/Levodopa given worsening tremor, memory, and hearing loss. S/p arm nerve block on 01/21/11. Recommend follow up with the patient’s neurologist.

DISCUSSION:

PLAN:
Medication changes: No.

Laboratory: Chem 7.

Diet: Patient advised to follow a healthy low fat, salt and carbohydrate diet.

Exercise recommendations: Regular exercise is strongly recommended.

Hypertension Instructions: The patient was instructed to monitor their blood pressure twice daily and provide me with the records.

Preventive Medicine: It is important that the patient follow up with their primary physician for preventative medicine follow ups including yearly prostate exam and annual physical exam.

Follow Up: The patient was advised to return to the office for follow up in 2 days or earlier if he has any medical problems.

Emergency recommendations: The patient was advised to call 911 or go to the emergency room if the patient’s condition worsens or does not improve.

——————————————————————————————————————————————————-

Check in time: 09:39 AM Check out time: 11:14 AM

Electronically signed: 07/06/2016 03:15 PM BENZUR, URI

G8427 Med.with dosage and verification documented; 1036F CURRENT TOBACCO NON-USER CAD CAP COPD PV DM; 99213 Office/outpatient visit, est, mod; G8419 BMI abnormal. No followup plan documented

Uri M. Ben-Zur, M.D., F.A.C.C.
Interventional Cardiology / Invasive Electrophysiology

18200 Ventura Blvd
Tarzana, CA 91356
Phone (818) 986-0911 Fax (818) 986-9301
Date of visit: 07/05/2016
Reason for Visit:
Requesting Physician:
I had the opportunity to evaluate on the date stated above. I have reviewed the past medical history, symptoms and current therapy. In addition, I have examined the patient and based on my findings have provided my overall impression, outlining my treatment and plans in the summary below.

CHIEF COMPLAINT /HISTORY OF PRESENT ILLNESS:

is an extremely pleasant 81 year old male with a past medical history of non-obstructive coronary artery disease, paroxysmal atrial fibrillation, hypertension, hyperlipidemia and large cell, B-cell lymphoma involving the iliac bone diagnosed in 08/1990 treated with chemotherapy and radiation.

The patient is being seen frequently given labile INR’s. The patient presents today for anticoagulation surveillance.

The patient denies chest pain, shortness of breath, palpitations, dizziness, syncope.

The patient’s systolic blood pressure averages 110 mmHg according to his home monitor. Mr. RAICH is following an exercise program. The patient states that he walks a 2.5 mile route close to his house in the hills of Tarzana. He follows a healthy diet.

At the time of his last visit, no medication changes were made.

Overall, states that he is stable.
PAST MEDICAL HISTORY:
Cardiovascular:
Atrial Fibrillation.
Coronary Artery Disease.
Hyperlipidemia.
Hypertension, benign essential.
Constrictive Pericarditis.
Pericardial effusion, unclear etiology.
Respiratory:
Pulmonary granulomatous disease.
Pleural effusions, bilateral.
Gastroenterology:
Diverticulosis.
Diverticulitis, in 1997.
H/o possible autoimmune hepatitis diagnosed in October 2005. The patient is being followed by Dr. Saab at the UCLA liver clinic.
Neurology:
Alzheimer’s.
Genitourinary:
Benign Prostatic Hyperplasia.
Hydronephrosis. Left kidney, per CT scan on 05/27/15.
Nephrolithiasis.
Psychiatry:
Depression.
Hematology/Lymphatic:
H/o large cell cleaved and non cleaved B-cell lymphoma, diagnosed 1990. Treated with 9 courses of MBACOD chemotherapy and radiotherapy.
Marginal cell low grade lymphoma per esophageal biopsy on 09/02/15.
Endocrine:
Hyperglycemia since February 2006, thought secondary to Prednisone use.
SURGICAL HISTORY:
Adenoidectomy.
Cardiac catheterization 05/06/15.
Left pleurocentesis 05/28/15.

CURRENT MEDICATIONS:
1 Colcrys 0.6 Mg Tablet SIG: Take 1 tab by mouth every other day
2 Prednisone 1 Mg Tablet SIG: take one tablet PO twice a week.
3 Lexapro 10 Mg Tablet SIG: Take 1 tab by mouth once daily
4 Warfarin Sodium 1 Mg Tablet SIG: 5/6/6 mg alt PO QD
5 Namenda 5 Mg Tablet SIG: one tab PO BID

ALLERGIES / INTOLERANCES:
Corticosteroids (Glucocorticoids), simvastatin, Amiodarone, colchicine

SOCIAL HISTORY:
Caffeine use. He consumes 1-2 servings per day
He is widower with three children, one with diabetes mellitus.
No Alcohol use
No Illegal drug use
No Tobacco use
Occupation: attorney.

FAMILY HISTORY:
Mother deceased at age 80 from gastric cancer.
Father deceased at age 60 from myocardial infarction, first myocardial infarction at age 44.
REVIEW OF SYSTEMS:
Constitutional Symptoms: (-) fever, (-) chills, (-) night sweats, (-) fatigue, (-) weakness, (-) changes in appetite or weight.

Integumentary: (-) rash, (-) lumps, (-) itching, (-) dryness, (-) acne, (-) discoloration, (-) recurrent skin infections, (-) changes in hair, nails or moles.

Neck: (-) swollen glands, (-) enlarged thyroid, (-) neck pain.

Respiratory: (-) cough, (-) hemoptysis, (-) cyanosis, (-) wheezing, (-) nocturnal choking or gasping.

Cardiovascular: (-) chest pain, (-) edema, (-) high blood pressure, (-) irregular heartbeat, (-) orthopnea, (-) palpitations, (-) paroxysmal nocturnal dyspnea, (-) shortness of breath.

Gastrointestinal: (-) abdominal pain, (-) heartburn, (-) constipation, (-) diarrhea, (-) nausea, (-) vomiting, (-) hematochezia, (-) melena, (-) change in bowel habits.

Genitourinary: (-) dysuria, (-) frequency, (-) urgency, (-) hesitancy, (-) polyuria, (-) nocturia, (-) hematuria, (-) urinary incontinence, (-) flank pain, (-) change in urinary habits.

Musculoskeletal: (-) muscle pain, (-) joint pain, (-) bone pain.

Peripheral Vascular: (-) intermittent claudication, (-) cramps, (-) varicose veins, (-) thrombophlebitis.

Neurological: (+) memory loss.
Neurological: (+) memory loss.
Endocrine: (-) heat or cold intolerance, (-) excessive sweating, (-) excessive thirst, (-) excessive hunger, (-) excessive urination, (-) hirsutism, (-) change in ring or shoe size.

Hematologic/Lymphatic: (-) anemia, (-) easy bruising, (-) excessive bleeding, (-) history of blood transfusions.

PHYSICAL EXAM:
Vitals:
BP: 130/66(Left Arm)(Supine)
Pulse: 88(Left brachial)

Weight: 160 lbs
Height: 5′ 10″
BMI: 22.96
BSA: 1.89
BP: 94/53(Left Arm)(Standing)
Pulse: 93(Left brachial)(Standing)(Regular)

General Appearance: The patient is an extremely pleasant 81 year old male who looks younger than his stated age is well developed and well nourished in no apparent distress. His body habitus is within normal limits. His mood is normal.
HEENT: Normocephalic and atraumatic. Pupils are equally round and reactive to light and accommodation. Extraocular muscles are intact. Patient’s neck is supple with no jugular venous distention, left carotid bruit was heard and carotid pulses are +2/2. Normal carotid artery upstroke bilaterally. Palpation is not painful and no thyromegaly nor lymphadenopathy can be appreciated.
Respiratory: Clear to auscultation bilaterally without wheezes or rhonchi. No intercostal retractions or accessory muscle use were noted.
Cardiovascular: Regular rate and rhythm. Cardiac point of maximal impulse at left fifth intercostal space mid-clavicular line. Normal S1, S2 with physiologic splitting of S2. II/VI systolic murmurs. No thrills, rubs, gallops, or clicks were heard.
Gastroenterology: Abdomen is soft non-tender and non-distended. Positive bowel sounds, no hepatomegaly or splenomegaly was noted. Abdominal bruit.
Extremities: Pulses were 2+ throughout bilaterally. No cyanosis, edema or clubbing.
Musculoskeletal: Motor strength is appropriately intact throughout bilaterally.
Neurologic: Patient is alert and oriented x3 with deep tendon reflexes appropriately intact throughout bilaterally, non-focal.
Psychiatric: Patient is conscious, cooperative, and well-oriented to time, place, and person. There are no mood swings or psychotic features. Patient’s insight is good. Memory and judgement are intact.
DIAGNOSTIC DATA:

Encounter long term anticoagulant. Date: Jul 5, 2016.
INR: 2.6.
Current Dose: : 5/6/6 mg PO QD alternating dose.
Therapeutic Goal/INR: 2.0 – 3.0.
Medication adjustments: Continue same Coumadin dose.
Next INR test: Jul 7, 2016.

ELECTROCARDIOGRAM: Date performed: Jan 18, 2016.
Indication: Occasional shortness of breath.
Interpretation: Rate: 68 bpm; Rhythm: Normal sinus rhythm and 1st degree AV Block; Right bundle branch block and Left hemifasicular block- anterior.
Conclusion: Abnormal ECG.

2D COLOR DOPPLER ECHOCARDIOGRAPHY:
Date: Jan 18, 2016 Indication: History of recurrent pericardial effusion and pleural effusions.

Findings:
Left atrium: Dimension: 3.1 cm. (Men: 3-4 cm/Women: 2.7-3.8 cm). Normal in size.
Left ventricle:
-LVIDd = 3.3 cm (Men:4.2-5.9 cm/Women: 3.9-5.3cm).
-LVIDs = 2.8 cm (2.0-4.1 cm).
-IVS = 1 cm (0.6-1.1 cm).
-LVPWd = 0.7 cm (0.6-1.1 cm).
Wall kinesis: There is E-A flow reversal suggestive of diastolic dysfunction.

Right atrium: Normal in size and shape and shows no signs of ASD, mass or thrombus.
Right ventricle: Normal in size and shape and shows no signs of VSD, mass or thrombus.

Aortic valve: Peak Velocity = 2 m/sec (1.0 – 1.7 m/sec). Mild aortic valve stenosis.
Mitral valve: Mild regurgitation. No sclerosis. No stenosis. No valve prolapse.
Tricuspid valve: Normal tricuspid valve.
Pulmonic valve: Normal pulmonic valve.
Aorta: No evidence of dissection, coarctation or aneurysm of the aorta.

Left ventricle ejection fraction: 60 %.

Pericardium: No effusion or calcification.
Venous: Inferior vena cava: Normal diameter with normal respiratory variation.

Recommendations:
Decrease dose of Colchicine.

CAROTID ARTERY DUPLEX SCAN:
Date of Study: May 5, 2015.
Indication: Left carotid bruit.

Measurements:
Left:
CCA distal peak velocity: 77 cm/sec.
CCA end diastolic velocity: 16 cm/sec.
ICA distal peak velocity: 102 cm/sec.
ICA end diastolic velocity: 32 cm/sec.
ECA distal peak velocity: 121 cm/sec.
ECA end diastolic velocity: 16 cm/sec.
Left vertebral artery showed antegrade flow.
ICA/CCA: 1.3.
Right:
CCA distal peak velocity: 84 cm/sec.
CCA end diastolic velocity: 14 cm/sec.
ICA distal peak velocity: 76 cm/sec.
ICA end diastolic velocity: 24 cm/sec.
ECA distal peak velocity: 96 cm/sec.
ECA end diastolic velocity: 5 cm/sec.
Right vertebral artery showed antegrade flow.
ICA/CCA: 0.9.

Impression/Comments:

Findings: Bilateral mild plaque.

Plan:
Non-obstructive disease.
Will intensify medical therapy.

.
ABDOMINAL AORTA DUPLEX SCAN:
Date: May 8, 2015 Indication: Indication: bruit.

Aorta:
Proximal Aortic Diameter: 2.3 cm.
Proximal Aortic Peak Systolic Velocity: 1.07 m/s.
Mid Aortic Diameter: 1 cm.
Mid Aortic Peak Systolic Velocity: 1.16 m/s.
Distal Aortic Diameter: 0.8 cm.
Distal Aortic Peak Systolic Velocity: 1.18 m/s.

Technical impression:
Within normal limits. Mild plaque seen in abdominal aorta.
CT Angiography Cardiac/Chest by Dr. Madyoonon performed on 03/05/2007 showed:

1. 40% stenosis in the distal Left Main Coronary artery secondary to dense calcification.
2. 40% stenosis at the ostium of the LAD secondary to dense calcification. Mild to moderate stenosis (30 to 50%) in the proximal-to-mid LAD secondary to eccentric complex plaque.
3. No significant disease in the Circumflex coronary artery.
4. No significant disease in the dominant RCA.
5. Normal ventricular function and chamber dimension.
6. No significant structural mitral or aortic valve abnormality.
7. Normal aortic root and ascending aorta diameters. There is no evidence of aneurysm or dissection.
8. No severe stenosis is seen; however, the presence of complex plaque in the proximal LAD warrants aggressive management of lipids to secondary prevention levels.
CT CHEST (UNIVERSITY IMAGING CENTERS)

1. Status post old healed granulomatous disease.
2. No evidence of mediastinal or hilar mass, lymphadenopathy or pulmonary nodules.
3. Apparent small subsegmental atelectasis vs. focal scarring, superior segment, right lower lobe.
4. Multiple low attenuating lesions involving the liver, of a nonspecific nature. Liver ultrasound is recomended if further evaluation is needed.

CT Angiogram Chest by Dr. E. Koiln performed on 03/05/2007

1. 27 x 26 mm ground-glass density consolidation in the apical segment of the left upper lobe. The differential diagnosis includes infection or bronchoalveolar carcinoma.
2. Old granulomatous disease with two right and one left calcified pulmonary nodules. The largest noncalcified pulmonary nodule in the right posterior segment, right upper lobe measuring 2.9 mm. CT follow up for the left apex ground glass consolidation will also follow this nodule.
3. Seven liver lesions measuring up to 2 cm in maximal diameter. These likely represent cysts or hemangiomata.
4. Cardiac findings are reported separately.

CT ANGIOGRAM CHEST (Supplementary Comparative Report)
(Compared with CT chest, 02-06-07, University Imaging Medical Center)

1. The 27 x 26 mm ground-glass consolidation in the apical segment of the left upper lobe is new, since the prior study of 2/6/07. The development of this infiltrate in a four-week period suggests infection. Since the patient is currently asymptomatic and has a history of immunocompromise and is currently taking Prednisone, the differential diagnosis includes Pneumocystis pneumonia or other infection (such as Mycobacterium TB or MAC). Clinical correlation and 4-6 week CT follow up, if clinically indicated, are recommended for further evaluation. The differential diagnoses includes PCP, TB, MAC, viral pneumonia versus localized hemorrhage or hypersensitivity pneumonitis. The rapid development over the one-month interval from the prior study makes neoplasm less likely.
2. Second 10 mm ground-glass infiltrate anterior to the larger opacity is seen in the anterior portion of the apical left upper lobe on the 3/5/07 study. This is also new and not present on the prior study of 2/6/07. This also likely represents infection.

Carotid artery duplex scan by Dr. L. Chespak Date: 08/19/2005. Indication: R/0 Carotid Stenosis.
Impression:
1. Up to 27 percent stenosis with in the right external carotid artery.
2. Up to 19 percent stenosis with in the left common carotid artery.
3. There are no significant changes when compared to the previous study dated 12/24/2001.
Cardiac Catheterization: 05/06/15.
Coronary artery disease, small vessel. The plan is for medical therapy.
– Left main was nonobstructive.
– Left anterior descending was nonobstructed and circumflex artery was nonobstructive. There was a diagonal vessel, approximately 85 percent ostial stenosis off the LAD. It was a small vessel, less than 2 mm in diameter.
– Right coronary artery had approximately 20 percent ostial stenosis, which might have been mild spasm and approximately 60 percent ostial PLV stenosis
– LVEDP measured approximately 30 mmHg.
– Normal overall LV function with an ejection fraction of approximately 65 percent. – Pullback across the aortic valve showed no significant gradient.
PLV lesion: Adenosine was infused 180 mcg/kg per minute. After 2 minutes, the FFR was 1.0. Therefore, the stenosis and the PLV was not significant.

Other: CARDIAC MRI 06/05/15:
– Moderate pericardial effusion which contains mixed signals, likely fibrinous materials. Patchy enhancement of the pericardium is seen. These findings are consistent with pericarditis. Although the pericardium is only mildly thickened, the pericardium appears to demonstrate reduced compliance, suggestive of constrictive pericarditis, The additional moderate pericardial effusion likely adds to the constrictive physiology. There is a mild septal bounce noted. Further MR imaging with real time cine imaging during respiration may be considered for the assessment of ventricular interdependence.
– Decreased left ventricular systolic function. The EF is 40.7%.
– Mild aortic stenosis and mild regurgitation.
– Mild mitral and tricuspid regurgitation.
– Moderate bilateral pleural effusion.
– Mild left atrial enlargement.
– Soft tissue mass within upper esophagus, measuring 6.4 x 1.8 cm.

CHEST X-RAY 05/29/15:
IMPRESSION –
There has been an increase in the appearance of a right pleural effusion and
bilateral basilar lung atelectasis over the past one day(s). The heart size
and osseous structures are stable.

DOUBLE CONTRAST ESOPHAGRAM 05/27/15.
Findings: Deglutition was normal as was esophageal motility and mucosal pattern. On the air contrast portions of the study a curvilinear shadow is present in the upper thoracic esophagus corresponding to the abnormal area seen on the preceding CT scans. The contour is smooth and no mucosal abnormality is identified. The finding is not visualized on the video swallows or on the single contrast images but is best seen on the double contrast images of the upper cervical esophagus. This may represent an intramural mass.
IMPRESSION –
1. Possible intramural mass in the upper thoracic esophagus corresponding to the CT finding

ABDOMINAL ULTRASOUND 05/26/15:
Findings: The patient is status post cholecystectomy. There is no biliary dilatation with common duct measuring 5 mm. The liver span is 16.2 cm. There is an 18 x 17 x 16 mm simple cyst present in the left hepatic lobe corresponding to the CT finding. Additional 9 x 8 x 7 mm cyst is present in the right hepatic lobe. The pancreas is normal. The right kidney measures 11.1 cm in length and the left kidney measures 9.9 cm. Both kidneys are normal and are non obstructed. The spleen, aorta and inferior vena cava are normal. No free fluid or mass is identified. Bilateral pleural effusions are present.
IMPRESSION –
1. Status post cholecystectomy
2. 2 hepatic simple cysts are present corresponding to the lesions previously
identified on the CT scan bilateral pleural effusions
3. The study is otherwise unremarkable.

CT CHEST 05/26/15:
FINDINGS:
A somewhat patulous upper esophagus is re identified. Once again, an apparently intraluminal oblong soft tissue dense focus is re identified along the upper esophagus, measuring roughly 3.1 x 1.8 x 3.8 cm. No extraluminal extension of the lesion or contrast extravasation is identified. Query possible esophageal wall lesion, which may or may not be pedunculated. Correlation with endoscopy is recommended. An esophagram and/or MRI may also be considered for further evaluation. Increased mediastinal lymphadenopathy is noted, measuring up to 1.9 x 1.5 cm along the right paratracheal region. The thyroid is unremarkable. The heart size is within normal limits. Aortic and coronary arterial calcifications are again noted. An intervally enlarged pericardial effusion is noted. Intervally increased small to moderate bilateral pleural effusions are identified. Associated bilateral basilar lung dependent atelectasis is present. Degenerative changes of the spine and shoulders are re identified.
IMPRESSION –
1. Possible lesion along the upper esophagus, as described above. Correlation
and follow up are recommended.
2. Increased mediastinal lymphadenopathy.
3. Increased pericardial and bilateral pleural effusions.

CT ABDOMEN 05/26/15:
FINDINGS:
Abdomen: Surgical clips are identified along the gallbladder fossa, consistent with prior cholecystectomy. Minimal associated left pneumobilia and gas along the pancreatic duct are also identified. Bilateral hepatic low-density lesions are noted; query possible cysts. Minimal perihepatic, perisplenic, and mesenteric ascites is identified. The spleen, kidneys, and adrenal glands are grossly unremarkable. The stomach and small bowel are partially collapsed and fluid filled, limiting evaluation. Degenerative changes of the spine are re identified.
Pelvis: The urinary bladder is unremarkable. The prostate is enlarged and demonstrates calcification. Colonic diverticulosis is present. No free fluid, inflammatory change, or significant lymphadenopathy is noted.
IMPRESSION –
1. Status post cholecystectomy. Associated pneumobilia and pancreatic ductal
gas are noted.
2. Hepatic low-density lesions, suspicious for possible cysts.
3. Ascites.
4. Enlarged prostate.
5. Colonic diverticulosis.
VENTILATION/PERFUSION LUNG SCAN 05/24/15:
Findings: The lungs are well perfused bilaterally. No significant perfusion defects are identified. There is no evidence of ventilation/perfusion mismatch.
IMPRESSION – Findings consistent with a low probability of pulmonary embolus.
TTE 6/2/15 for Constriction Evaluation
Normal LV size; normal wall thickness; normal systolic function. Septal bounce noted with intermittent septal flattening suggestive of ventricular interdependence. LVEF 55-60%. Normal right ventricular size and normal systolic function. Mild left atrial enlargement, mild mitral valve regurgitation. Calcific mild aortic stenosis with trace aortic regurgitation with normal proximal sized aortic root. Echo findings fit criteria for pericardial constriction.

CORONARY ANGIOGRAPHY FINDINGS 6/3/15
Left main is angiographically abnormal with a 30% ostial stenosis. LAD angiographically abnormal with 20% proximal stenosis and 60% stenosis of the ostium of the 2nd diagonal branch. Left circumflex artery is angiographically abnormal with a proximal 30% stenosis. Right coronary artery is angiographically abnormal with mild luminal irregularities.
Hemodynamics: Simultaneous LV and RV tracings revealed significant discordance between LV and RV pressures with respiration.

MRI CHEST 6/6/2015
Redemonstration of pedunculated intraluminal soft tissue mass in the upper esophagus, grossly measuring 27x19mm with low grade enhancement. Findings remain nonspecific, however given location and imaging findings favor fibrovascular polyp. Moderate pericardial effusion with significant pericardial thickening and enhancement.

Last colonoscopy: 10/2006. No significant findings. Last prostate exam / urological evaluation: 06/2007 Mild enlarged prostate report by the patient. Last PSA: 3.0 on 09/28/2006.

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DIAGNOSIS/ASSESSMENT:

RECURRENT ATRIAL FIBRILLATION WITH RAPID VENTRICULAR RESPONSE.
Of note is that Amiodarone was previously discontinued given prolonged QT. The patient is on Coumadin. The patient was advised to avoid alcohol, caffeine, and other stimulants, which may precipitate his condition. Close follow-up advised. He is to contact me if he has a recurrence of palpitations.

H/O PERICARDIAL EFFUSION/CONSTRICTIVE PERICARDITIS.
H/O PNEUMONIA.
No evidence of pericardial effusion on repeat echocardiography. Discontinue Colcrys. The patient was advised of the importance of following a healthy diet and daily aerobic exercise. He was instructed to contact me if he has a recurrence of shortness of breath or he develops new symptoms. Will follow him clinically.

SMALL VESSEL CORONARY ARTERY DISEASE.
Cardiac catheterization on 05/06/05 showed non obstructive coronary arteries. The patient was advised of the importance of following a healthy diet and daily aerobic exercise.

H/O RECURRENT PERICARDIAL EFFUSION AND PLEURAL EFFUSIONS
Echocardiography on 1/18/16 showed no effusion or calcification in the pericardium. Inferior vena cava normal diameter with normal respiratory variation. LVEF: 60%. The patient is on Colchicine.

HYPERLIPIDEMIA.
LDL 179 mg/dL and HDL 52 mg/dL on 06/07/16. Pravachol was discontinued given elevated LFTs. Low fat, healthy diet advised.

ORTHOSTATIC HYPOTENSION.
Asymptomatic. Recommend that the patient rise slowly from a lying down/seated position, and remain well hydrated at all times. He is to contact me or emergency services if he develops dizziness.

ESOPHAGEAL MASS.
LOW GRADE MARGINAL CELL LYMPHOMA.
Upper esophageal soft tissue mass, measuring 6.4 cm x 1.8 cm per MRI performed on 06/05/15. Biopsy performed on 09/02/15 revealed marginal cell, low grade Lymphoma. The plan is to monitor the patient with serial labs and imaging for now. Defer management to Dr. Dosik of hematology/oncology who notes that the patient is asymptomatic from his para-esophageal lymphoma and will follow-up with him in 3 months.

DEPRESSION/BEREAVEMENT/ANXIETY.
The patient’s wife died 11/2015. The patient denies suicidal ideation. Defer management to his internist.

ALZHEIMER’S DEMENTIA.
Mild. Defer management to his internist.

DISCUSSION:

PLAN:
Medication changes:
Discontinue Colcrys.

Procedures performed today: INR.

Diet: Patient advised to follow a healthy low fat, salt and carbohydrate diet.

Exercise recommendations: Regular exercise is strongly recommended. Recommend gradual increase in daily aerobic exercise.

Anxiety recommendations: The patient was advised to practice stress reduction techniques, including but not limited to meditation, deep breathing, yoga and exercise as tolerated.

Preventive Medicine: It is important that the patient follow up with their primary physician for preventative medicine follow ups including yearly prostate exam and annual physical exam.

Follow Up: The patient was advised to return to the office for follow up in 1 week or earlier if he has any medical problems.

Emergency recommendations: The patient was advised to call 911 or go to the emergency room if the patient’s condition worsens or does not improve.

——————————————————————————————————————————————————-
Changed/Discontinued Medication(s):
Discontinued: COLCRYS 0.6 MG TABLET – no longer needed
Discontinued By Other MD: VIAGRA 100 MG TABLET – expense – over $500
Check in time: 09:49 AM Check out time: 10:12 AM

Electronically signed: 07/06/2016 03:16 PM BENZUR, URI

G8427 Med.with dosage and verification documented; 1036F CURRENT TOBACCO NON-USER CAD CAP COPD PV DM; 85610 Prothrombin time; 99213 Office/outpatient visit, est, mod; G8419 BMI abnormal. No followup plan documented

Uri M. Ben-Zur, M.D., F.A.C.C.
Interventional Cardiology / Invasive Electrophysiology

18200 Ventura Blvd
Tarzana, CA 91356
Phone (818) 986-0911 Fax (818) 986-9301
Date of visit: 07/05/2016
Reason for Visit:
Requesting Physician:
I had the opportunity to eval on the date stated above. I have reviewed the past medical history, symptoms and current therapy. In addition, I have examined the patient and based on my findings have provided my overall impression, outlining my treatment and plans in the summary below.

CHIEF COMPLAINT /HISTORY OF PRESENT ILLNESS:

is an extremely pleasant 81 year old female with a past medical history of mitral valve prolapse, hyperlipidemia and hypothyroidism. She is accompanied today by her husband.

The patient is being seen frequently given labile INR’s.

The patient walked in today with complaints of severe dizziness. No other associated symptoms noted.

The patient denies weakness, dizziness, focal neurological deficit, chest pain, syncope.

She does not monitor her blood pressure at home. The patient does not follow an exercise program. She follows the weight watchers diet. She states that she eats primarily vegetables and fruit.

Overall, states that she is not feeling well.
PAST MEDICAL HISTORY:
Cardiovascular:
Atrial Fibrillation. Diagnosed 07/05/16.
Hyperlipidemia.
Hypertension, benign essential.
Mitral Valve Prolapse.
Paroxysmal Atrial Tachycardia.
VPC’s / APC’s as per Holter monitor on 10/12/2006
Episode of sustained palpitations in October 2006 thought secondary to Didrex (appetite suppressant)
S/P arthroscopic repair of her left rotator cuff on 09/25/13.
Musculoskeletal:
Knee injury
Left Shoulder Rotator Cuff tear.
Neurology:
Cerebrovascular accident 05/16/16.
Psychiatry:
Anxiety.
Depression.
Endocrine:
Hypothyroidism.
SURGICAL HISTORY:
Cosmetic surgery
TEE 05/31/16.

CURRENT MEDICATIONS:
1 Synthroid 25 Mcg Tablet SIG: PO QD
2 Aspirin 325 Mg Tablet SIG: one tab PO QD
3 Lipitor 80 Mg Tablet SIG: take one tablet daily
4 Warfarin Sodium 1 Mg Tablet (Other MD) SIG: 7.5mg/7.5mg/10mg alt PO QD

ALLERGIES / INTOLERANCES:
Thyroid

SOCIAL HISTORY:
Marital Status: The patient is married with 3 healthy children.
Smoking/tobacco use: No history of smoking.
Alcohol: Non alcoholic beverage drinker.
Recreational drug use: She denies recreational drug use.
Caffeine Intake: She does not drink coffee, tea, soda or any other caffeinated drinks and beverages.
Occupation: housewife.

FAMILY HISTORY:
Mother deceased at the age 78 of a Myocardial infarction. She had a h/o brain tumor.
Father deceased at the age of 78 of Alzheimers disease
Brother died of ” cancer “, (unclear details) in his 40’s.
REVIEW OF SYSTEMS:
Constitutional Symptoms: (-) fever, (-) chills, (-) night sweats, (-) fatigue, (-) weakness, (-) changes in appetite or weight.

Integumentary: (-) rash, (-) lumps, (-) itching, (-) dryness, (-) acne, (-) discoloration, (-) recurrent skin infections, (-) changes in hair, nails or moles.

Respiratory: (-) cough, (-) hemoptysis, (-) cyanosis, (-) wheezing, (-) nocturnal choking or gasping.

Cardiovascular: (-) chest pain, (+) dizziness, (+) dyspnea with exertion, (+) edema, (-) high blood pressure, (+) irregular heartbeat, (-) orthopnea, (-) palpitations, (-) paroxysmal nocturnal dyspnea, (+) shortness of breath, (-) Syncope.
Cardiovascular: (+) dizziness, (+) dyspnea with exertion, (+) edema, (+) irregular heartbeat, (+) shortness of breath.
Gastrointestinal: (-) abdominal pain, (-) heartburn, (-) constipation, (-) diarrhea, (-) nausea, (-) vomiting, (-) hematochezia, (-) melena, (-) change in bowel habits.

Genitourinary: (-) dysuria, (-) frequency, (-) urgency, (-) hesitancy, (-) polyuria, (-) nocturia, (-) hematuria, (-) urinary incontinence, (-) flank pain, (-) change in urinary habits.

Musculoskeletal: (-) muscle pain, (-) joint pain, (-) bone pain.

Peripheral Vascular: (-) intermittent claudication, (-) cramps, (-) varicose veins, (-) thrombophlebitis.

Neurological: (-) numbness, (-) tingling, (-) tremors, (-) seizures, (-) vertigo, (-) memory loss, (-) any focal or diffuse neurological deficits.

Endocrine: (-) heat or cold intolerance, (-) excessive sweating, (-) excessive thirst, (-) excessive hunger, (-) excessive urination, (-) hirsutism, (-) change in ring or shoe size.

Hematologic/Lymphatic: (-) anemia, (-) easy bruising, (-) excessive bleeding, (-) history of blood transfusions.

PHYSICAL EXAM:
Vitals:
BP: 129/82(Left Arm)(Supine)
Pulse: 87(Left brachial)(Supine)

Weight: 168 lbs
Height: 5′
BMI: 32.81
BSA: 1.79
BP: 125/95(Left Arm)(Standing)
Pulse: 55(Left brachial)(Standing)

General Appearance: The patient is an extremely pleasant 81 year old female who looks younger than her stated age. is well developed and well nourished in no apparent distress. Her body habitus is obese, her mood is normal.
HEENT: Normocephalic and atraumatic. Pupils are equally round and reactive to light and accommodation. Extraocular muscles are intact. Patient’s neck is supple with no jugular venous distention, no carotid bruit heard and carotid pulses are +2/2. Normal carotid artery upstroke bilaterally. Palpation is not painful and no thyromegaly nor lymphadenopathy can be appreciated.
Respiratory: Clear to auscultation bilaterally without wheezes or rhonchi. No intercostal retractions or accessory muscle use were noted.
Cardiovascular: Irregular heart rhythm. Cardiac point of maximal impulse at left fifth intercostal space mid-clavicular line. Normal S1, S2 with physiologic splitting of S2. No murmurs, thrills, rubs, gallops, or clicks were heard.
Gastroenterology: Abdomen is soft non-tender and non-distended. Positive bowel sounds, no hepatomegaly or splenomegaly was noted. No bruits were heard.
Extremities: Pulses were 2+ throughout bilaterally. No cyanosis or clubbing. Trace to +1 pitting ankle edema, non-erythematous, NTTP.
Musculoskeletal: Motor strength is appropriately intact throughout bilaterally.
Neurologic: Patient is alert and oriented x3 with deep tendon reflexes +2/4 throughout bilaterally, non-focal.
Psychiatric: Patient is conscious, cooperative, and well-oriented to time, place, and person. There are no mood swings or psychotic features. Patient’s insight is good. Memory and judgement are intact.
Skin: No skin rash, subcutaneous nodules, lesions or ulcers observed.
DIAGNOSTIC DATA:

Encounter long term anticoagulant. Date: Jul 5, 2016.
INR: 2.1.
Current Dose: : 7.5/7.5/10 mg PO QD alternating dose.
Therapeutic Goal/INR: 2.0 – 3.0.
Medication adjustments: Increase coumadin to 7.5 / 10mg PO QD.
Next INR test: Jul 12, 2016.

Chest X-ray:
Sep 23, 2013.
TECHNIQUE: Chest X-ray is Erect PA and left lateral views.
FINDINGS: There is mild cardiomegaly present. The thoracic aorta is tortuous and partially calcified. There are a few thin discoid strands present in the left lower lung field; otherwise, the lungs are clear. No pulmonic consolidation nor pleural effusions are seen. The osseous structures are intact.
IMPRESSION: Cardiomegaly and aortic atherosclerosis. A few thin discoid strands are noted in the left lower lung field.

ELECTROCARDIOGRAM: Date performed: Jul 5, 2016.
Indication: Irregular heartbeat.
Interpretation: Rate: 127 bpm; Rhythm: Atrial fibrillation and Non-specific ST-T changes.
Conclusion: Abnormal ECG.

2D COLOR DOPPLER ECHOCARDIOGRAPHY:
Date: Jul 5, 2016 Indication: Occasional dizziness and abnormal EKG.

Findings:
Left atrium: Dimension: 4.1 cm. (Men: 3-4 cm/Women: 2.7-3.8 cm). It is mildly dilated.
Left ventricle:
-LVIDd = 2.8 cm (Men:4.2-5.9 cm/Women: 3.9-5.3cm).
-LVIDs = 2.4 cm (2.0-4.1 cm).
-IVS = 1.5 cm (0.6-1.1 cm).
-LVPWd = 1.2 cm (0.6-1.1 cm).
Ventricular thickness: There is moderate LV concentric hypertrophy.

Right atrium: Normal in size and shape and shows no signs of ASD, mass or thrombus.
Right ventricle: RVSP: 33 mmHg (15-25 mmHg). Normal in size and shape and shows no evidence of VSD or mass.

Left ventricle ejection fraction: 60 %.

Pericardium: Trace anterior free space.
Venous: Inferior vena cava: Normal diameter with normal respiratory variation.

Holter Monitoring 24hrs: Hookup Date: May 23, 2016..
Indication: evaluation of palpitations and s/p CVA.
Findings:
Normal sinus rhythm. Occasional APCs. Occasional VPCs. Brief episodes of PAT 6 beats at 140bpm, recurrent.
Conclusions: Recommend anticoagulant therapy.

CAROTID ARTERY DUPLEX SCAN:
Date of Study: Sep 11, 2015.
Indication: Left carotid bruit.

Measurements:
Left:
CCA distal peak velocity: 43 cm/sec.
CCA end diastolic velocity: 12 cm/sec.
ICA distal peak velocity: 64 cm/sec.
ICA end diastolic velocity: 25 cm/sec.
ECA distal peak velocity: 66 cm/sec.
ECA end diastolic velocity: 10 cm/sec.
Left vertebral artery showed antegrade flow.
ICA/CCA: 1.4.
Right:
CCA distal peak velocity: 72 cm/sec.
CCA end diastolic velocity: 15 cm/sec.
ICA distal peak velocity: 55 cm/sec.
ICA end diastolic velocity: 18 cm/sec.
ECA distal peak velocity: 61 cm/sec.
ECA end diastolic velocity: 10 cm/sec.
Right vertebral artery showed antegrade flow.
ICA/CCA: 0.76.

Impression/Comments:

Findings: Bilateral mild plaque.

Plan:
Non-obstructive disease.
Will intensify medical therapy.

LOWER EXTREMITIES VENOUS DOPPLER: Mar 28, 2016.
Indication: +1 Bilateral leg edema.
Impression: Normal venous flow with normal collapse with compression. Normal augmentation of venous flow with calf compression. No evidence of venous insufficiency with valsalva manuever or abdominal pressure. Normal lower extremities.
No evidence of deep venous thrombosis or venous outflow obstruction of the lower extremities by duplex scanning.

RENAL ARTERY-AORTA DUPLEX SCAN: May 18, 2015.
Indication: Hypertension (401.1).

Measurements:
Left Renal Peak Systolic Velocity:
Proximal: 0.5 m/s [<1.0].
Mid: 0.57 m/s [<1.0].
Distal: 0.4 m/s [<1.0].
Renal/Aortic Ratio: 0.9. [<3.5].
Right Renal Peak Systolic Velocity:
Proximal: 0.68 m/s [<1.0].
Mid: 0.89 m/s [<1.0].
Distal: 0.39 m/s [<1.0].
Renal/Aortic Ratio: 1.4. [<3.5].

Aorta:
Proximal Aortic Diameter: 2.3 cm.
Mid Aortic Diameter: 1.3 cm.
Distal Aortic Diameter: 1 cm.
Aortic Peak Systolic Velocity: 0.63 m/s.

Kidney:
Left:
kidney length: 9.8 cm [8.5-15.0 cm].
Kidney Width: 5.4 cm. ( 4.5-5.0 cm].
Kidney Depth (trans): 5.4 cm. [4.5-5.0].
Cortical Thickness: 1.5 cm. [1.1 cm].
Parenchymal Flow /Waveform:
Upper Early Systolic Peak Present.
Mid Early Systolic Peak Present.
Lower Early Systolic Peak Present.
Resistive Index: 0.79 [<0.75] (PSV-EDV/PSV).

Right:
kidney length: 9.9 cm [8.5-15.0 cm].
Kidney Width: 4.2 cm. ( 4.5-5.0 cm].
Kidney Depth (trans): 4.8 cm. [4.5-5.0].
Cortical Thickness: 1 cm. [1.1 cm].
Parenchymal Flow /Waveform:
Upper Early Systolic Peak Present.
Mid Early Systolic Peak Present.
Lower Early Systolic Peak Present.
Resistive Index: 0.67 [<0.75]
(PSV-EDV/PSV).

Technical impression:
Within normal limits.

ABDOMINAL AORTA DUPLEX SCAN:
Date: Sep 23, 2013 Indication: Indication: Hypertension (401.1).

Aorta:
Proximal Aortic Diameter: 2.2 cm.
Proximal Aortic Peak Systolic Velocity: 0.71 m/s.
Mid Aortic Diameter: 1.7 cm.
Mid Aortic Peak Systolic Velocity: 0.58 m/s.
Distal Aortic Diameter: 1.3 cm.
Distal Aortic Peak Systolic Velocity: 0.75 m/s.

Technical impression:
Within normal limits. Minimal plaque seen in abdominal aorta.
Treadmill stress test with echocardiographic imaging 10/12/2006: indication: palpitations and abnormal electrocardiogram. The patients abnormal electrocardiogram led to exercise stress testing for the evaluation of coronary ischemia.
The patient was told the risk and benefits of exercise stress test including but not limited to myocardial infarction, vascular compromise and death. The patient asked appropriate questions. All questions were answered and the patient wished to proceed and gave her informed consent. The patient completed 6 minutes 0 seconds on the Bruce Protocol achieving a heart rate of 120 beats per minutes, which represents approximately 75% of predicted maximal heart rate. The patient did not complain of any chest pain. She did not complain of shortness of breath or dizziness. Exercise test was terminated secondary to generalized fatigue.
Electrocardiogram showed no significant ST changes. Atrial premature contractions/ ventricular premature contractions / dysrhythmias were not seen. The oxygen saturation was more than 95% throughout exercise test.
Most recent stress echocardiography reveals normal left ventricular function at rest with an adequate increase in left ventricular function in response to exercise. Color flow Doppler was performed to assess the severity of mitral regurgitation. Doppler echo was done to evaluate the blood flow across the mitral valve. Stress echocardiography showed IVS 1.2 cm, PW 1.1cm, LA 3.2cm, AO 1.7cm, AO at sinus valsalva 3.9cm, mild MR, mild AI, trace TR, RVSP 39 mmHg, mild MVP, mildly thickened mitral valve leaflets. Ejection fraction 65%.
Impression: Assessment of exercise test revealed good hemodynamic response to exercise; Adequate oxygen saturation and negative electrocardiographic changes without inducible ischemia or evidence of obstructive coronary artery disease. The patient has a low probability of obstructive coronary artery disease based on exercise stress / echocardiography testing performed. It was discussed with the patient that, notwithstanding the results of the exercise stress test, coronary artery disease may be present. Exercise stress testing is only one diagnostic tool and may be falsely negative in the presence of significant coronary artery disease. Other diagnostic tests may be in order if new symptoms develop or if symptoms recur or change in quality or duration. The patient was instructed to contact me immediately and contact emergency medical services in this event. The patient’s valvular dysfunction has remained stable.
Holter monitoring 10/12/2006, indication: palpitations, shows normal sinus rhythm, occasional APCs, occasional to frequent PVC’s and occasional ventricular bigeminy.

Carotid artery duplex scan Date: 03/20/09. Indication: dizziness, right carotid bruit.
RIGHT
Right External Carotid Artery Velocity: 67 cm/s
Right Distal Internal Carotid Artery Velocity: 85 cm/s
Right Proximal Internal Carotid Artery Velocity: 53 cm/s.
Right Proximal Common Carotid Artery Velocity: 68 cm/s
Right Internal Carotid Artery/Common Carotid Artery Ratio: 1.3
Right vertebral artery flow is antegrade.
LEFT
Left External Carotid Artery Velocity: 68 cm/s.
Left Distal Internal Carotid Artery Velocity: 65 cm/s.
Left Proximal Internal Carotid Artery Velocity: 58 cm/s
Left Proximal Common Carotid Artery Velocity: 65 cm/s
Left Internal Carotid Artery/Left Common Carotid Artery Ratio: 0.9
Left vertebral artery flow is antegrade.
Impression:
RIGHT: Calcified plaque in ECA less than 10% stenosis in RT carotid artery and Calcified plaque in ICA less than 10% in RT carotid artery.
LEFT: Plaque in bulb less than 10% in the LT carotid artery, Mild intimal thickening in LT CCA and Plaque in ICA less than 20% in LT carotid artery.
Plan: Intensify medical therapy and non-obstructive disease.

Preventative medicine check-ups: Last cervical / vaginal PAP smear: 07/2009, within normal limits, Last mammogram: 07/2009, within normal limits, last colonoscopy: 07/2007 within normal limits, Herpes Zoster vaccine: administered on 10/12/2006.
REGADENOSON MYOCARDIAL PERFUSION PET: 09/24/13
Test results indicate a low <10% likelihood for the presence of angiographically significant coronary artery disease.

Other: ECHOCARDIOGRAM 01/03/11 by Dr. Burnam
Impression:
1. Normal LVEF and wall motion, borderline concentric LVH, normal systolic and Grade I abnormal diastolic function. LVEF greater than 65%.
2. The aortic valve is trileaflet and calcified.
3. No AS and mild AR
4. The Mitral Valve is somewhat sclerotic with mild MR, no MS, or MVP.

CAROTID ULTRASOUND 01/03/11 by Dr. Burnam
Impression:
1. Mild atherosclerotic changes bilaterally
2. No hemodynamically significant stenosis in seen

DUPLEX STUDY OF THE ABDOMINAL AORTA, ILIAC ARTERIES, AND INFERIOR VENA CAVA 01/03/11 By Dr. Burnam
Impression:
Minimal atherosclerotic changes of the abdominal aorta. No evidence of abdominal aortic aneurysm. There are no significant changes when compared to the prior study dated 10/06/09.

Urinalysis Report: Date: Oct 20, 2014.
Indication: Dysuria.
Leukocytes: No Leukocytes present.
Nitrite: Negative.
Urobilinogen: (Normal 0.2 – 1).
Protein: Negative.
Ph: 5.
Blood: Blood: Negative.
Specific Gravity: 1.025.
Ketone: Negative.
Bilirubin: Negative.
Glucose: Negative.

————————————————————————————————————————————————————
DIAGNOSIS/ASSESSMENT:

ATRIAL FIBRILLATION- NEWLY DIAGNOSED.
MILD LEFT ATRIAL DILATION.
Duration unclear. Today’s EKG revealed atrial fibrillation with rapid ventricular response rate of 127 bpm, and non specific ST-T changes. Echocardiography revealed mildly dilated left atrium, no evidence of mitral valve prolapse. I had a long discussion with the patient regarding therapeutic options, including medical therapy, DCCV, RF ablation, AV nodal ablation and permanent pacemaker implant, Watchman Device, and MAZE procedure, and the attendant risks and benefits. Given her current symptoms, she was advised to proceed immediately to the nearest ER for further evaluation and inpatient management. She agreed.

DIZZINESS.
Possibly secondary to atrial fibrillation with rapid ventricular response. Today’s EKG revealed atrial fibrillation with rapid ventricular response rate of 127 bpm, and non specific ST-T changes. Normal left ventricular function, EF 60%, per echocardiography today. The patient was advised to proceed immediately to the nearest ER for further evaluation and inpatient management.

SHORTNESS OF BREATH.
Mild. Stable. Multifactorial. Patient with arrhythmias, sedentary lifestyle, and multiple risk factors for coronary artery disease. Today’s EKG revealed atrial fibrillation with rapid ventricular response rate of 127 bpm, and non specific ST-T changes. Echocardiography revealed normal left ventricular function, EF 60%. Low likelihood of angiographically significant coronary artery disease per myocardial perfusion scanning. The patient was advised to proceed immediately to the nearest ER for further evaluation and inpatient management.

S/p CEREBROVASCULAR ACCIDENT.
H/o cryptogenic ischemic stroke, causing mild resolving aphasia and right sided hemiparesis on 05/16/16 per Dr. Morvarid of neurology. The stroke was within the left dominant M1 distribution. There was some suggestion of showering radiographically. There was no clear cardioembolic source identified. 24 Hr Holter monitoring revealed occasional APCs, occasional VPCs, and recurrent PAT at 140 bpm. Negative TEE on 05/31/16. In house INR today was 2.1. Increase Coumadin dose to 7.5/10 mg ALT PO QD.

LOWER EXTREMITY EDEMA
Improved. The patient was advised to raise her lower extremities above heart level for 30 minutes, 3-4 times daily. Strongly recommend low salt diet.

H/O PAROXYSMAL ATRIAL TACHYCARDIA.
24-Hour Holter monitoring revealed occasional atrial premature contractions, occasional ventricular premature contractions and recurrent PAT, 6 beats at 140 bpm. The patient was advised to avoid caffeine, alcohol, and other stimulants, which may precipitate her condition. Recommend practicing stress reduction techniques.

HYPERTENSION, ESSENTIAL BENIGN.
Moderate left ventricular hypertrophy noted on echocardiography. No evidence of renal artery stenosis/abdominal aortic aneurysm on diagnostic studies. Recommend that the patient monitor her blood pressure at home and provide me with the records. Target systolic blood pressure in the 110-120 mmHg range recommended. Low salt diet advised. She may need medical therapy.

HYPERLIPIDEMIA.
LDL 89 mg/dL, HDL 72 mg/dL per labs on 05/26/16. The patient was recently started on Lipitor, and she is tolerating it well so far. Low fat diet advised.

OTHER:
– HYPOTHYROIDISM: TSH 9.52 mlU/L on 05/26/16. Defer management to the patient’s internist.
– Depression. The patient denies suicidal ideation at this time. She self-discontinued Lexapro. Defer management to Dr. Friar.

DISCUSSION:

PLAN:
EMERGENCY ROOM: The patient was instructed to proceed directly to the nearest hospital for further evaluation and management. She declined EMS services. Patient will transport themselves to the hospital now.

Medication changes:
Increase Coumadin dose to 7.5/10 mg alt PO QD.

Procedures performed today: INR, EKG, Complete Echocardiogram.

Diet: Patient advised to follow a healthy low fat, salt and carbohydrate diet.

Exercise recommendations: Regular exercise is strongly recommended.

Hypertension Instructions: The patient was instructed to monitor their blood pressure twice daily and provide me with the records.

Anxiety recommendations: The patient was advised to practice stress reduction techniques, including but not limited to meditation, deep breathing, yoga and exercise as tolerated.

——————————————————————————————————————————————————-
Changed/Discontinued Medication(s):
Discontinued By Other MD: COUMADIN 10 MG TABLET
Check in time: 10:11 AM Check out time: 11:14 AM

Electronically signed:

99215 Office/outpatient visit, est, high; G8427 Med.with dosage and verification documented; 1036F CURRENT TOBACCO NON-USER CAD CAP COPD PV DM; 93000 Electrocardiogram, complete (ECG); 93306 echo 2Dw/doppler echo/color flow doppler; G8419 BMI abnormal. No followup plan documented