"CHIEF COMPLAINT

Follow-up of chronic problems.

HISTORY OF PRESENT ILLNESS

Brian White is a 58-year-old male with a past medical history significant for congestive heart failure and hypertension, who presents today for follow-up of his chronic problems.

The patient states he has been feeling out of sorts lately. He is not sure if it is due to the change in the seasons or due to performing lots of projects and some construction on his home. He reports fatigue and lightheadedness. This has been going on for about 5 weeks. While exerting energy, he has experienced some shortness of breath and chest cramps. The patient also notes a slight cough, but he is not sure if it is just the change in seasons.

He feels bloated every once in a while. His diet has been a little bit of a struggle. They had construction on their kitchen begin over Labor Day weekend, and have been eating less healthy food as a result.

Regarding his heart failure, he has been pretty good with his salt intake. He has been pretty good about his diet since the last year and is staying on top of that as much as possible. The patient has continued to utilize Lasix daily.

For his hypertension, this has been well controlled with lisinopril 20 mg a day. He has continued to monitor his blood pressure regularly.

The patient did the review of systems sheet when he checked in. He denies weight gain, swelling in the lower extremities, fevers, chills, dizziness, nausea, vomiting, and diarrhea.

REVIEW OF SYSTEMS

 Constitutional: Endorses fatigue. Denies fevers, chills, or weight loss.
 Cardiovascular: Endorses chest pain or dyspnea on exertion.
 Respiratory: Endorses cough and shortness of breath.
 Gastrointestinal: Endorses bloating.

PHYSICAL EXAMINATION

 Neck: JVD 8 cm.
 Respiratory: Rales bilateral bases.
 Cardiovascular: 3/6 systolic ejection murmur.
 Musculoskeletal: 1+ pitting edema bilateral lower extremities.

RESULTS

X-ray of the chest demonstrates a mild amount of fluid in the lungs.

Echocardiogram demonstrates decreased ejection fraction of 45% and mild mitral regurgitation.

ASSESSMENT AND PLAN

Brian White is a 58-year-old male with a past medical history significant for congestive heart failure and hypertension, who presents today for follow up of his chronic problems.

Congestive heart failure.
 Medical Reasoning: The patient reports increased fatigue, dizziness, and chest discomfort on exertion. He also exhibits some jugular venous distention, lung base crackles, and lower extremity edema on exam today. He has been compliant with his current medications but admits to dietary indiscretion lately. His recent echocardiogram demonstrated a reduced ejection fraction of 45%, as well as mitral regurgitation.
 Additional Testing: We will order a repeat echocardiogram.
 Medical Treatment: Increase Lasix to 80 mg daily.
 Patient Education and Counseling: I advised the patient to monitor and record his daily weight and report those to me via the patient portal. He will contact me should he continue to experience any dyspnea.

Hypertension.
 Medical Reasoning: This is well controlled based on home monitoring.
 Medical Treatment: Continue lisinopril 20 mg daily.
 Patient Education and Counseling: I advised him to monitor and record his blood pressures at home and report these to me via the patient portal.

Patient Agreements: The patient understands and agrees with the recommended medical treatment plan."