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An established office patient with severe exacerbation of CHF
CC : Follow-up CHF
Interval History : Patient presents for follow-up of CHF. He has a history of significant ischemic cardiomyopathy with an ejection fraction of 30%. Hypertension has been well controlled on current medications, but the patient has noted worsening lower extremity edema over the past one to two weeks. He also complains of severe SOB over the past three days. CAD has been stable with no active chest pain. The patient states he has been compliant with medications, but has not been watching his salt intake carefully.
Medications
Lasix 40 mg po bid
KCL 20 mEq po bid
Lisinopril 10 mg po qd
Coreg 6.25 mg po bid
Imdur 30 mg po qd
ASA 81 mg po qd
ROS : A complete ROS was performed and documented and was positive for PND and orthopnea, but negative for chest pain or anginal equivalents. ROS is otherwise non-informative. For details please refer to today’s ROS form on the chart.
PFSH : Complete PFSH taken during an earlier encounter was re-examined and reviewed with the patient. For details please refer to the dictated note in this chart dated 12/12/2003. Since that time, patient underwent cardiac catheterization with RCA stent deployment on 3/24/04; otherwise nothing new to add today.
Physical Exam
General: Some respiratory distress at rest, but able to speak in full sentences, well nourished.
Vitals: 180/90, 64, 26
HEENT: Moist mucous membranes, positive JVD
Lungs: Bibasilar crackles about half way up
Cardiovascular: RRR, no MRGs
Abdomen: Soft, non-tender, no HSM
Extremities: 3 + bilateral lower extremity edema; no digital cyanosis
Labs: BUN 32, creatinine 1.9, HCO3 24, K 3.8, HGB 12
Assessment
- Severe exacerbation of systolic CHF
- Poorly controlled hypertension
- Hypervolemia with severe lower extremity edema and exam findings suggestive of pulmonary vascular congestion
- History of CAD, which appears to be controlled
Plan
- Increase lasix to 80 mg po bid times three days
- Start zaroxyln 2.5 mg po qd times three days
- Increase KCL to 30 mEq po bid times three days
- Repeat renal profile in three days
- The importance of a low sodium diet was explained to the patient
- Patient was instructed to go immediately to ER if SOB acutely worsens or if any chest pain develops
- Return visit in three days with lab
For a detailed breakdown of this note with tips and advice see 99215 E/M Insight
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