Geriatric Comprehensive Assessment

Reason for Assessment:
- Shortness of breath and leg swelling

History:
Mr. Thompson reports progressive shortness of breath over the past two weeks, becoming winded with minimal exertion such as walking short distances or climbing stairs. He experiences nocturnal symptoms, including shortness of breath when lying flat, requiring three pillows to sleep, and reports coughing and breathlessness at night. He has noticed bilateral leg swelling that worsens by the end of the day, accompanied by a sensation of tightness. He has gained approximately six pounds over the last ten days without dietary changes. He denies chest pain but reports occasional palpitations. He has a history of hypertension and diabetes, for which he is currently on medication. His father had a heart attack in his 60s. Mr. Thompson confirms adherence to his prescribed blood pressure and diabetes medications.

Cognition:

Falls/mobility:

Medical History:
- Hypertension, diabetes

Functional Assessment:

Social History:

Other Geriatric Syndromes:
- Weight changes: Weight gain of approximately six pounds over the last ten days
- Dietary intake: No changes in appetite or diet reported

Physical Examination:

Investigations:
- Chest X-ray, ECG, echocardiogram, BNP, CBC, electrolytes, and renal function tests have been ordered

Impression:
Mr. Thompson presents with symptoms and signs suggestive of acute decompensated congestive heart failure, including progressive dyspnea, orthopnea, paroxysmal nocturnal dyspnea, bilateral lower limb edema, and recent weight gain. His history of hypertension and diabetes, as well as a family history of cardiac disease, are notable risk factors.

Plan and Recommendations:
- Initiated low-dose furosemide (Lasix) for symptomatic relief of fluid overload
- Advised careful monitoring of fluid intake and output
- Counseled on the importance of a low-sodium diet and daily weight monitoring
- Referred to a heart failure clinic for specialized follow-up and ongoing management