Home Visit Followup

Introduction:
Patient seen at home.
Family/caregiver augmented history obtained.

Subjective:
Chief Complaint:
Shortness of breath and leg swelling

History of Present Illness:
Mr. Thompson is a male with a history of hypertension and diabetes mellitus.

He reports progressive dyspnea on exertion over the past two weeks, now occurring with minimal activity such as walking from the kitchen to the living room. He also experiences orthopnea, requiring three pillows to sleep, and nocturnal cough. He notes bilateral lower extremity edema that worsens by the end of the day and a weight gain of approximately six pounds over the past ten days without dietary changes. He denies chest pain but reports intermittent palpitations. He states he is compliant with his prescribed antihypertensive and antidiabetic medications. Family history is notable for his father having a myocardial infarction in his 60s. Allergies, social history, medical history, and family history reviewed and updated as appropriate.

Functional status: Needs assistance with activities of daily living.

Observed mobility: Unsteady.

Environmental factors: No safety hazards noted.

Caregiver support: Present.

Review of Systems:
Mr. Thompson endorses shortness of breath with exertion and when lying supine, nocturnal cough, bilateral lower extremity swelling, and recent weight gain. He reports intermittent palpitations. He specifically denies chest pain.

Past Medical History:
Mr. Thompson has a history of hypertension and diabetes mellitus, for which he reports full adherence to prescribed antihypertensive and antidiabetic medications without missed doses. He reports no history of myocardial infarction.

Past Surgical History:
Mr. Thompson reports no history of cardiac surgical interventions.

Current Medications:
Mr. Thompson is currently taking antihypertensive and antidiabetic medications as prescribed. He reports consistent adherence to his medication regimen and has not missed any doses.

Objective:
Vitals:

If vitals not obtainable: Home BP cuff unavailable, patient declined measurement, equipment not functioning

Physical Exam:
[General: Alert, in mild respiratory distress, oriented to person, place, and time.]
[HEENT: Normocephalic, atraumatic, mucous membranes moist, extraocular movements intact, nares patent.]
[Neck: Supple, no lymphadenopathy, no bruits, no thyromegaly.]
[Cardiovascular: Irregular heart rhythm, no murmurs, rubs, or gallops appreciated.]
[Pulmonary: Bibasilar crackles on auscultation, increased respiratory effort noted.]
[Abdomen: Bowel sounds present, non-tender, no distension, no organomegaly.]
[Extremities: 2+ pitting edema bilaterally to the mid-shin, no cyanosis or clubbing, peripheral pulses palpable.]
[Neurologic: No tremor or rigidity, grip strength intact, hip flexion strength preserved.]
[Gait: Unsteady, no assistive device observed.]
[Psychiatric: Insight and judgment intact, memory grossly normal, mood and affect appropriate.]

Data Reviewed:
No labs, imaging, or consult reports reviewed within the specified time window.

Medications discussed: Antihypertensive and antidiabetic medications, patient reports full compliance. Initiation of furosemide discussed.

Assessment and Plan:
Acute on chronic diastolic (congestive) heart failure (I50.33), likely decompensated.

Plan:

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.

Dr. Emily Carter
Regional Medical Center