Clinical note · #49
Hospital & observation
Date: 2024-07-04
Admitting Physician: Dr. Jane Smith, DO
Chief Complaint: Shortness of breath
HPI
The patient is a 75-year-old female presenting with progressive shortness of breath over the past week. The patient reports orthopnea and paroxysmal nocturnal dyspnea. She denies any recent chest pain or fever.
ROS
Cardiovascular: No chest pain, orthopnea present.
Respiratory: Shortness of breath, no cough.
Gastrointestinal: No nausea or vomiting.
Neurological: No dizziness or weakness.
PFSH
Past Medical History: Congestive heart failure, atrial fibrillation.
Family History: Mother had chronic heart disease.
Social History: Non-smoker, no alcohol use.
Physical Examination
Vital Signs: BP 140/80, HR 100, RR 22, Temp 98.4°F.
Cardiovascular: Irregular rhythm, S3 present.
Respiratory: Bibasilar crackles.
Abdomen: Soft, non-tender.
Extremities: 2+ pitting edema in lower extremities.
MDM
Chest X-ray shows pulmonary congestion.
BNP levels elevated.
Diagnosis: Acute exacerbation of congestive heart failure.
Plan
Admit to telemetry.
Start diuretics and oxygen therapy.
Monitor fluid status and electrolytes.