VASCULAR SURGERY CLINIC SOAP NOTE

Patient Name:
DO

Yuan S. Kao

DOB: 09/12/1937
M

Patient ID: 009110

Age: 77

PCP: Marie Aaron,

Sex:

Date of Exam: 08/31/2014

CHIEF COMPLIANT: History of right calf claducation, presents in follow up.
SUBJECTIVE: Mr. Koa, a delightful Korean gentleman was seen about 1 month ago. He was put
on Pletal after noting that he catches pain on walking. In the meantime we have ordered a
duplex scan of his right leg. He has had some success with Pletal, although he said he watched
some palpitations after starting it. The patient mistakenly dropped his Metoprolol and said that
the palpitations went away. He is still taking the Pletal and having no trouble with it and has not
been on his beta- blocker. I have instructed him that this is not the best course for him, that he
needs to take the beta- blocker. He has a small chance of getting the side effects if he restarts
his beta- blocker. The side effects where likely due to the Pletal and his body has gotten used to
that now. I will continue with both, since he is getting relief from the claudication stand point, as
he reports approach distance walking in his right leg. Past history and medications are
unchanged, he continues to not smoke. A 12-point ROS is noncontributory.
OBJECTIVE: Well developed, well-nourished, elder Korean male in no acute stress vital signs show
Temperature: 98, BP: 140/72, Pulse: 86, Respiration: 22.HEEMT exam: Normal cephalic
atraumatic, Neck: supple, soft with 2+ carotid upstrokes, Lung scan: Equal expansion bilaterally,
clear to auscultation. Heart is regular. Abdominal is soft and non-tender. Extremities show 2+
femoral pulses bilaterally. His right leg has decreased pulses at the foot compared to his left foot.
Neurologic: range of change 3, at non vocal exam.
X-RAY DATA: Duplex scan was performed which reveals his proximal SFA including in the midline
as well as distal at the carotid canal. There is reconstitution of his popliteal artery, and he has
monophasic singles distal. His carotid duplex shows moderate stenosis of his left carotid artery,
which is actually fairly stable compared to the previous study done one year ago.
ASSESSMENT: Mr. Koa is a delightful gentleman with right leg claducation that has improved on
Pletal. I have instructed him to restart his beta blocker and to continue the Pletal.
PLAN: He will see how the Pletal and beta blocker work and return to my clinic in 3 months. In the
meantime he is to make an appointment with his clinical PCP for his annual physical exam next
month with lab work, and send copies to me.

_________________________
Thomas Burges, MD
Vascular Surgery
TB: LM
D: 8/31/2014
T: 9/02/2014

C: Marie Aaron, DO, Family Practice