Cardiac Procedure Note

INDICATION FOR PROCEDURE
Follow-up for congestive heart failure, fluid retention and breathing difficulties.

RELEVANT MEDICAL HISTORY
History of congestive heart failure with recent hospitalization in March for acute decompensation and pulmonary congestion. Echocardiogram during hospitalization revealed mildly reduced left ventricular ejection fraction (49-50%) and pulmonary congestion. Laboratory evaluation showed a hemoglobin level of 107 grams per liter.

PERFORMING PHYSICIAN(S)
Evan Lin

FINDINGS
The patient presents with persistent lower extremity edema extending from the feet to the lower legs, with minimal improvement since hospital discharge despite initiation of furosemide at 20 mg. Diuresis has been variable, with frequent urination on some days and absence of urination on the day of encounter. Slight reduction in swelling is reported. The patient endorses intermittent dyspnea, including nocturnal episodes that disrupt sleep and cause awakening with gasping for air. No frequent chest pain or palpitations. Recent fall and xerostomia attributed to diuretic therapy. Echocardiogram demonstrated mildly reduced left ventricular ejection fraction (49-50%) and evidence of pulmonary congestion. Hemoglobin level was 107 grams per liter. Cardiac auscultation revealed normal heart sounds without murmurs, gallops, or rubs. Pulmonary auscultation indicated no significant fluid in the lungs. Peripheral examination showed significant lower extremity edema.

RECOMMENDATIONS AND POST-PROCEDURE PLAN
- Monitoring: Monitor for improvement in edema and dyspnea, and for any worsening symptoms.
- Medications: Increase furosemide dose to 40 mg to enhance diuresis and address fluid retention.
- Access site care:
- Activity restrictions:
- Follow-up instructions: Avoid excessive fluid intake, maintain dietary sodium restriction, and use strategies to alleviate nocturnal dyspnea such as sleeping in an upright position or with an extra pillow. Follow-up appointment scheduled in approximately four weeks to reassess condition and evaluate effectiveness of treatment plan.

Next appointment: In approximately four weeks.

Sincerely,

Evan Lin