Cardiology OP New Consult - Concise

Diagnosis  
Acute diastolic (congestive) heart failure (I50.31).  
Left ventricular failure, unspecified (I50.1).  
Anemia, unspecified (D64.9).

Medications  
Furosemide 20 mg once daily.

Summary Plan  
The patient was advised to increase the dose of furosemide to 40 mg to improve diuresis and help alleviate fluid retention. A follow-up appointment was scheduled in approximately four weeks to monitor symptom progression and determine the need for repeat diagnostic evaluations.  
The patient was instructed to avoid excessive fluid intake and to restrict dietary sodium. Education was provided on addressing nocturnal dyspnea, including recommendations to sleep in an upright position and use an extra pillow for support.

I met this patient in clinic today. This letter is written to summarise their recent presentation and management plan. The patient was referred due to follow-up for congestive heart failure, fluid retention and breathing difficulties.

The patient reports experiencing significant bilateral lower extremity edema extending to the lower legs and nocturnal dyspnea that interrupts sleep, beginning approximately one week ago. The patient describes intermittent episodes of dyspnea but denies frequent or persistent shortness of breath. The patient reports only minimal improvement in edema with current diuretic therapy, with urinary frequency varying from hourly on some days to no urination on the day of this visit. The patient notes persistent oral dryness and occasional thirst, which is attributed to diuretic therapy. The patient experienced a recent fall. There is no report of chest pain or palpitations.

On examination, cardiac auscultation revealed normal heart sounds with no significant murmurs or gallops. Pulmonary auscultation indicated no significant fluid in the lungs. Peripheral examination showed bilateral lower extremity edema extending to the lower legs.

An echocardiogram demonstrated mildly reduced left ventricular ejection fraction (49-50%) and evidence of fluid overload. Laboratory testing revealed a hemoglobin level of 107 grams per liter.

The patient will continue on their current medications, including furosemide. I have advised the patient to continue with fluid and sodium restriction and to sleep in an upright position with an extra pillow for support. I have arranged a follow-up appointment in four weeks to assess their progress and review their medications. I have advised the patient to contact the clinic if symptoms worsen.