Cardiac Monitor Follow up Visit

Date: 2026-02-02

RE: Shortness of breath

I had the opportunity of reassessing Mr. Thompson in a consultation to review his recent symptoms. Mr. Thompson has multiple cardiovascular risk factors. He has a history of hypertension and diabetes mellitus. His father had a myocardial infarction in his 60s.

Mr. Thompson presents with progressive dyspnea over the past two weeks, now occurring with minimal exertion and associated with orthopnea requiring three pillows to sleep, nocturnal cough, and bilateral lower extremity edema developing by the end of the day. He reports an unintentional weight gain of approximately six pounds over the last ten days. He denies chest pain but reports intermittent palpitations described as a sensation of his heart racing without clear provocation. He confirms adherence to his prescribed antihypertensive and antidiabetic medications. He denies any history of heart attacks or heart surgeries.

Impression and Plan
Mr. Thompson presents with progressive dyspnea, orthopnea, and bilateral lower extremity edema, suggestive of possible fluid overload or cardiac dysfunction. He denies chest pain but reports intermittent palpitations.

Thank you for involving me in his care.

Yours sincerely,

Jordan Lee, MD