GeriCare Acute Template

Subjective:
Chief Complaint:
Shortness of breath and leg swelling

HPI:
Mr. Smith presents with progressive shortness of breath over the past two weeks, now occurring with minimal exertion and when lying supine. He requires three pillows to sleep due to orthopnea and experiences nocturnal cough. He reports bilateral lower extremity swelling that worsens by the end of the day and a weight gain of approximately 6 pounds in the last 10 days without dietary changes. He denies chest pain but notes intermittent palpitations. He is adherent to his antihypertensive and antidiabetic medications. This visit is medically necessary to evaluate and manage his 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:
The patient reports taking blood pressure and diabetes medications daily without missing any doses. No further details provided.

Allergies:
No allergy information provided.

Review of Systems (ROS):
Constitutional: Reports recent weight gain of approximately 6 pounds over the past 10 days.
Respiratory: Reports worsening shortness of breath on exertion and when lying down, requiring three pillows to sleep, and nocturnal cough.
Cardiovascular: Denies chest pain. Reports intermittent palpitations described as heart racing.
Gastrointestinal: No findings reported.
Other systems: No significant findings.

Objective:
Vitals:
No vital signs provided.

Physical Exam:
No physical examination findings provided.

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, electrocardiogram, echocardiogram, B-type natriuretic peptide, complete blood count, electrolytes, and renal function tests ordered.

Face-to-face time spent on history taking, assessment, counseling regarding medication adherence, dietary modifications, and follow-up instructions.

Sign Off:
The documentation transcribed by Alex Chen accurately reflects my findings.
Alex Chen
Regional Medical Center