Established Visit Subjective Question & Answer Guide (With Explanation)

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Original Question

ESTABLISHED VISIT Sex: F AGE: 67 DOS: 1/1/20XX SUBJECTIVE: The patient initially underwent a left SFA Silver stent placement in July 20XX with a follow-up atherectomy in July 20XX of an intrastent stenosis as well as a left peroneal artery and posterior tibial artery mechanical thrombectomy. Currently she is doing well; however, she complains of intermittent left leg pain at night. Her leg pain is only associated when she rolls over and does not awaken her from her sleep with claudication-type symptoms. She has no new ulcerations and is able to walk short distances without much difficulty. She is currently on aspirin 81 mg per day as her stomach was unable to tolerate the regular-dose aspirin. There was a misunderstanding and then she was taking both a morning and an evening dose of 325 mg in addition to a baby aspirin. This was discontinued by Dr. Thomas who did notice that there was a problem, and she is now back to her baby aspirin. She has been off Plavix for three months. OBJECTIVE: On exam, both feet are symmetrically cool. On the right, there are 2+ common femoral, 1+ dorsalis pedis, and 2+ posterior tibial artery pulses. On the left, there are 2+ common femora, and 1+ dorsalis pedis and posterior tibial artery pulses. Minimal trace edema is noted bilaterally. RADIOLOGIC STUDIES: Arterial duplex ultrasound performed last week, continues to demonstrate biphasic waveforms throughout the continued turbulence in the proximal left SFA intrastent region. The ABI measures 0.78 via the DPA on the left and 1.05 on the right. The ABI is slightly decreased but this is thought to be due to technical changes. IMPRESSION: The patient is overall doing quite well. I believe that her leg pain symptoms are more related to her surgery that was performed following her arterial interventions rather than true claudication symptoms. Her arterial duplex ultrasound is essentially stable with a widely patent stent with continued slight increased turbulence in the proximal stent region. Biphasic waveforms are seen throughout. Left leg pain. PLAN: 1. Continue aspirin 81 mg indefinitely. 2. We will see her in three months for a follow up left lower extremity arterial duplex and visit. 3. She has been instructed that if she develops claudication-type symptoms or acute leg pain to notify us as soon as possible for further workup.

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