Virtual Thrombosis Consult

Subjective:
Chief Complaint:
Chronic heart failure and hypertension management follow-up.

History of Present Illness:
The patient reports low blood pressure measurements at home, with a reading of 90/53 mmHg this morning and 79/57 mmHg recorded yesterday at a dental clinic. These measurements were obtained using the patient’s home monitor and at the dental clinic, respectively. The patient denies dizziness, lightheadedness, or new or worsening dyspnea associated with these readings. Shortness of breath is noted only with abrupt initiation of vigorous exertion, such as rapidly ascending a mountainside, but resolves with continued activity, including walking for 20 minutes over hilly terrain. The patient’s spouse confirms the ability to ascend three flights of stairs without difficulty. No complaints related to the current medication regimen, recent hospitalizations, changes in chronic disease management, or new symptoms are reported. No cognitive disturbances, memory issues, or adverse effects from current therapy are noted. No additional concerns are raised by the patient or spouse.

There is no chest pain, shortness of breath, leg pain or swelling.

There is no recent surgery, trauma or immobility. No estrogen use. The review of system is negative with no constitutional symptoms.

Medication adherence is excellent. The patient denies any clinically significant bleeding history including hemoptysis, hematemesis, bright red blood per rectum, epistaxis or hematuria.

Past Medical History:
The patient has a history of chronic heart failure and hypertension. There are no reports of recent hospitalizations or changes in chronic disease management. The patient has been compliant with the prescribed medication regimen and denies any adverse effects from current therapy.

The Review of Systems:
Cardiovascular: No dizziness when blood pressure drops to low levels. 
Respiratory: No breathing issues or shortness of breath during regular activities. 
General: No complaints about the medications.

Objective:
Vital Signs:
Blood pressure readings include 90/53 mmHg this morning and 79/57 mmHg yesterday at the dentist's office.

Physical Examination:
Physical examination was deferred due to the telehealth nature of this consultation.

Assessment:
Impression:
The patient is stable with chronic heart failure and hypertension, with low blood pressure readings but no associated symptoms such as dizziness or shortness of breath.

The renal function is stable. There is no evidence of hepatic impairment. There are no drug-drug interactions.

I provided the patient with education on the importance of taking the anticoagulant consistently and what to do if he/she misses a dose. I recommend holding anticoagulant for 2 full days prior to any invasive procedure or surgery.

We also discussed strategies to mitigate the risks of bleeding today. The patient is not on any non-essential antiplatelet agent or NSAIDS. I recommend avoiding high-risk behaviours such as excessive alcohol use or extreme sports.

The patient should go to the emergency department if there is a concern for recurrent venous thromboembolism or bleeding. The signs and symptoms of DVT, PE and bleeding were reviewed with the patient today.

Problem:

1. Chronic heart failure (428.0)
2. Hypertension (401.9)

Plan:
The patient is advised to schedule a follow-up appointment in six months. They were instructed to contact xxx to arrange the next visit.