GeriCare Acute Template

Subjective:
Chief Complaint:
Shortness of breath and leg swelling

HPI:
Mr. Smith presents with progressive exertional dyspnea over the past two weeks. He reports increased shortness of breath when ambulating short distances, such as walking from the kitchen to the living room, and experiences orthopnea, requiring three pillows to sleep comfortably. He notes nocturnal cough and a sensation of breathlessness when lying flat. Bilateral lower extremity edema develops by the end of the day, described as puffy and tight. He has observed an unintentional weight gain of approximately six pounds over the last ten days without dietary changes. He denies chest pain but endorses intermittent palpitations. He continues to take his antihypertensive and antidiabetic medications as prescribed. This visit is medically necessary to evaluate and manage his acute symptoms.

Past Medical History:
Cardiovascular: Hypertension. No history of heart attacks. No history of heart surgeries.
Endocrine & Metabolic: Diabetes mellitus.
Other systems: No significant findings.

Social History:
No significant social history provided.

Current Medications:
1. Antihypertensive medication
2. Antidiabetic medication
The patient reports adherence to both medications. Specific names, dosages, frequencies, and routes are not provided.

Allergies:
No allergy information provided.

Review of Systems (ROS):
Constitutional: Reports recent weight gain of six pounds over ten days.
Cardiovascular: Denies chest pain. Reports intermittent palpitations.
Respiratory: Reports exertional dyspnea, orthopnea, and nocturnal cough.
Gastrointestinal: No findings reported.
Genitourinary: No findings reported.
Musculoskeletal: Reports bilateral lower extremity swelling.
Other systems: No findings reported.

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)

Investigations:
- Chest radiograph
- Electrocardiogram
- Echocardiogram
- B-type natriuretic peptide
- Complete blood count, serum electrolytes, and renal function tests

Face-to-face time was spent obtaining a detailed history, performing a review of systems, and counseling the patient regarding medication adherence, dietary modifications, and the importance of close follow-up.