GeriCare Acute Template

Subjective:
Chief Complaint:
Shortness of breath and leg swelling

HPI:
Mr. Smith presents with a two-week history of worsening shortness of breath, which is most pronounced with exertion and when lying supine. He reports the need to sleep with three pillows due to orthopnea and experiences nocturnal cough. He also notes bilateral lower extremity edema that worsens by the end of the day and a recent unintentional weight gain of approximately six pounds over ten days. He denies chest pain but describes intermittent palpitations. He is adherent to his antihypertensive and antidiabetic medications. The visit is medically necessary to evaluate and manage these acute symptoms.

Past Medical History:
Circulatory System: No history of heart attacks

Endocrine & Metabolic: Diabetes mellitus

Other Systems: No significant findings.

Social History:
No significant social history provided.

Current Medications:
1. Blood pressure medication
   - Dosage: 
   - Frequency: Daily
   - Route: 
   - Special Instructions: 

2. Diabetes medication
   - Dosage: 
   - Frequency: Daily
   - Route: 
   - Special Instructions: 

Allergies:
No known allergies reported.

Review of Systems (ROS):
Constitutional: Reports recent weight gain of approximately 6 pounds over 10 days.
Respiratory: Reports worsening exertional dyspnea, orthopnea, and nocturnal cough.
Cardiovascular: Denies chest pain. Reports intermittent palpitations.
Gastrointestinal: No significant findings.
Genitourinary: No significant findings.
Musculoskeletal: Reports bilateral lower extremity swelling.
Neurological: No significant findings.
Dermatological: No significant findings.

Assessment and Plan:
Assessment/Treatment Plan:
Diagnosis:
1. I50.9: Congestive heart failure (I50.2), likely decompensated (Initiate low-dose furosemide, monitor fluid intake and output, counsel on low-sodium diet and daily weights, refer to heart failure clinic for close follow-up)

Procedures:
- Chest X-ray: Ordered
- Electrocardiogram: Ordered
- Echocardiogram: Ordered
- B-type natriuretic peptide: Ordered
- Complete blood count, electrolytes, renal function: Ordered

Face-to-face time spent on history, examination, counseling, and documentation.

Sign Off:
The documentation transcribed by Alex Lee accurately reflects my findings.
I, Alex Lee, have reviewed and agree with the content of the note.
Clinic Name: [Add Clinic Name Here]