Cardiac Clinic Visit Note

DATE / REFERRING PHYSICIAN

PATIENT INFORMATION
- Name: Mr. Thompson
- Gender: male

REASON FOR CONSULTATION
- Shortness of breath

DIAGNOSES
- Shortness of breath (R06.02)
- Orthopnea (R06.01)
- Localized swelling, mass and lump, lower limb, bilateral (R22.43)
- Palpitations (R00.2)
- Abnormal weight gain (R63.5)

MEDICATIONS

ALLERGIES

HISTORY OF PRESENTING ILLNESS
- Patient presents with progressive dyspnea over the past two weeks.
- Relevant medical history includes hypertension and diabetes mellitus.
- Patient reports shortness of breath with minimal exertion, worsening over two weeks, orthopnea requiring three pillows, nocturnal coughing, bilateral lower extremity edema by end of day, unintentional weight gain of six pounds over ten days, and intermittent palpitations described as heart racing without provocation.

SOCIAL HISTORY

EXAMINATION

LABORATORY RESULTS

ECG

CARDIAC INVESTIGATIONS

IMPRESSION AND PLAN
- Summary: Mr. Thompson presents with progressive dyspnea, orthopnea, bilateral lower extremity edema, unintentional weight gain, and intermittent palpitations over the past two weeks. He has a history of hypertension and diabetes mellitus.
 
Thank you for involving me in the care of this patient.

Sincerely,
Dr. Samuel Lee