[doctor] hi , louis . how are you ? [patient] hi . good to see you . [doctor] it's good to see you as well . are you ready to get started ? [patient] yes , i am . [doctor] louis is a 58-year-old male here for follow up from an emergency room visit . so , louis , what happened ? [patient] yeah . i was playing tennis on saturday . it was really , really hot that day , very humid . and about after about a half an hour i was very short of breath , i was struggling breathing . i thought i was having a heart attack , got really nervous . so , my wife took me to the er and , uh , everything checked out , but i was just very upset about it . [doctor] okay . all right . and how have you been feeling since that time ? [patient] uh , foof , probably , probably about six hours after we got home , i felt very light-head and very dizzy and then , sunday , i felt fine . i just thought it was worth checking up with you though . [doctor] okay . and have you been taking all of your meds for your heart failure ? [patient] i have . i have . i've been , uh , very diligent with it . and , uh , i'm in touch with the doctor and so far , so good , other than this episode on saturday . [doctor] okay . and , and you're watching your diet , you're avoiding salt . have you had anything salty ? [patient] i cheat every now and then . you know , i try and stay away from the junk food and the salty foods . but , for the most part , i've been doing a good job of that . [doctor] okay . all right . um , and i know that they removed a cataract from your eye- [patient] mm-hmm . [doctor] . a couple of , like couple months ago . that's been fine ? [patient] that was three months ago , thursday , and everything's been fine ever since . [doctor] okay . so , no vision problems . [patient] no . [doctor] okay . and you had a skin cancer removed about five months ago as well . you've had a lot going on . [patient] yeah . it's been a really busy year . an- and again , so far , so good . that healed up nicely , no problems ever since . [doctor] okay . all right . um , so , why do n't we go ahead and we'll do a quick physical- [patient] mm-hmm . [doctor] . exam . hey , dragon , show me the blood pressure . so , here , your blood pressure is a little high . [patient] mm-hmm . [doctor] um , so , you know , i did see a report in the emergency room that your blood pressure was high there as well . [patient] mm-hmm . [doctor] so , we'll have to just kind of talk about that . uh , but let's go ahead and we'll examine you . [patient] sure . [doctor] okay ? [patient] mm-hmm . [doctor] okay . so , you know , looking at you , your neck is very supple . i do n't appreciate any fibular venous distention . your heart is a regular rate and rhythm , no murmur . your lungs have some fine crackles in them , bilaterally . and you have trace lower extremity edema in both legs . so , what that means , essentially , is that you may have some extra fluid on board , um , from eating salty foods- [patient] mm-hmm . [doctor] . along with this history of your congestive heart failure . but , let's go ahead and look at some of your results . hey , dragon , show me the ecg . so , this is , uh , a s- a stable ecg for you . this basically shows that you have some left ventricular hypertrophy which caused your congestive heart failure . um , let's go ahead and review your echocardiogram . hey , dragon , show me the echocardiogram . so , in reviewing the results of your echocardiogram , it shows that your pumping function of your heart is a little low , uh , but it's stable . and , you know , i think that we know this and we have you on the appropriate- [patient] mm-hmm . [doctor] medication therapy . and then , i just wan na be reminded about , um , the results of your skin biopsy . hey , dragon , show me the skin biopsy results . okay . and in reviewing the pathology report for your skin cancer- [patient] mm-hmm . [doctor] . you know , it looks like they got all of that and everything's fine . [patient] yep . [doctor] so , you know , my impression of you at this time , for the shortness of breath that you had in the emergency department , i think it was an exacerbation of your heart failure . and you probably had some , what we call , dietary indiscretion , you ate some salty food which made you retain some fluid . [patient] mm-hmm . [doctor] so , for that , i'm going to prescribe you , you know , an extra dose of lasix 80 milligrams , once a day . and , um , we're going to , uh , put you on some carvedilol 25 milligrams , twice a day . okay ? [patient] okay . perfect . [doctor] um , and i think from a , a cataract surgery standpoint and your skin cancer removal , everything seems to be fine and you're doing well , so i do n't think we need to adjust any of those medications . [patient] good to hear . [doctor] okay ? hey , dragon , order lasix 80 milligrams , once a day . hey , dragon , order carvedilol 25 milligrams , twice a day . okay . and the nurse will come in and she'll see you soon . okay ? [patient] great . [doctor] hey , dragon , finalize the note .
ASSESSMENT AND PLAN

The patient is a 58-year-old male who presents for follow-up after emergency room visit.
 
 ED follow-up and congestive heart failure.
 • Medical Reasoning: I believe his symptoms which led to his ED visit were due to an exacerbation of his heart failure. He admits to some dietary indiscretion, which likely resulted in fluid retention.
 • Medical Treatment: I will prescribe Lasix 80 mg once a day. I will also place him on carvedilol 25 mg twice a day.
 
 Status post basal cell carcinoma removal.
 • Medical Reasoning: He seems to be doing well and the removal site is well-healed. No change in treatment is necessary at this time.
 
 Status post cataract surgery.
 • Medical Reasoning: He seems to be doing well. We will continue to observe, but no treatment changes are needed today.
 
 