Cardiology New Consult

Dear Dr. 

Thank you for referring Mr. Smith for evaluation of his shortness of breath, orthopnea, bilateral lower extremity edema, and intermittent palpitations. I appreciate your assistance with the physical examination for this visit.

History of Present Illness:

Mr. Smith reports progressive dyspnea over the past two weeks, exacerbated by exertion such as walking short distances and ascending stairs. He experiences dyspnea when recumbent at night, requiring three pillows to sleep due to orthopnea and an associated cough. He notes bilateral lower extremity edema worsening by the end of the day, describing his legs as puffy and tight. He reports an unintentional weight gain of approximately six pounds over the past ten days without changes in dietary habits. He denies chest pain but describes intermittent palpitations as a sensation of his heart racing. He continues to take his antihypertensive and antidiabetic medications as prescribed without missed doses.

Cardiac Risk Factors:

- Hypertension history: Patient has a history of hypertension and is compliant with prescribed medications.
- Diabetes: Patient has a history of diabetes mellitus and is compliant with prescribed medications.
- Activity level: Reports limitation in exertion due to dyspnea (e.g., walking short distances, ascending stairs).
- Family history: Father experienced a myocardial infarction in his 60s.

Past Medical History:

- Hypertension
- Diabetes mellitus

Medications:

Mr. Smith is taking antihypertensive and antidiabetic medications daily as prescribed, without missing any doses.

Allergies:

No known allergies reported.

Family History: 

Father experienced a myocardial infarction in his 60s.

Surgical History: 

No history of heart surgeries is reported.

Review of Systems: 

Cardiovascular: Intermittent palpitations described as a sensation of heart racing. Denies chest pain.
Respiratory: Progressive shortness of breath exacerbated by exertion and when lying down at night, requiring the use of three pillows to sleep. Associated coughing at night.
General: Unintentional weight gain of approximately six pounds over the past ten days.
Musculoskeletal: Bilateral lower extremity edema that worsens by the end of the day, described as puffy and tight.

Impression and Plan:

Mr. Smith presents with progressive dyspnea, orthopnea, bilateral lower extremity edema, and intermittent palpitations. His symptoms are suggestive of potential cardiac or pulmonary etiology requiring further evaluation.

Sincerely,

Dr. Alex Chen, MD FRCPC