Hospital Diagnosis Note
Patient Name: Javier Jacobs
Date of Birth: March 15, 2050
Medical Record Number: 123456789
Date of Admission: October 1, 2094
Attending Physician: Dr. [Your Name]
Department: Internal Medicine
Chief Complaint:
The patient presents with persistent shortness of breath, chest discomfort, and fatigue for the past week.
History of Present Illness:
Javier Jacobs is a 44-year-old male with a history of hypertension and type 2 diabetes, both managed with medication. He reports progressively worsening shortness of breath, which is exacerbated by physical activity and alleviated slightly with rest. The chest discomfort is described as a dull ache, and there is no associated radiating pain. He denies fever, cough, or recent infections.
Past Medical History:
Hypertension, diagnosed 5 years ago, currently on Lisinopril 20 mg daily.
Type 2 Diabetes, diagnosed 3 years ago, managed with Metformin 500 mg twice daily.
No known history of cardiac disease or stroke.
Medications:
Allergies:
No known drug allergies.
Physical Examination:
General: Alert, oriented, in mild distress due to shortness of breath.
Vitals: Blood pressure 145/90 mmHg, heart rate 98 bpm, respiratory rate 22 bpm, oxygen saturation 94% on room air, temperature 36.8°C.
Cardiovascular: Regular heart sounds, no murmurs, gallops, or rubs. Mild peripheral edema noted.
Respiratory: Breath sounds decreased bilaterally with fine crackles at lung bases. No wheezing.
Abdomen: Soft, non-tender, no organomegaly.
Neurological: No focal deficits noted.
Diagnostic Tests:
Chest X-ray: Bilateral pulmonary infiltrates, consistent with pulmonary congestion.
EKG: Normal sinus rhythm, no ST-segment changes.
Blood tests: Elevated BNP (Brain Natriuretic Peptide), mild elevation in creatinine, blood glucose elevated at 180 mg/dL.
Impression/Diagnosis:
Congestive Heart Failure (CHF), likely decompensated.
Hypertension.
Type 2 Diabetes Mellitus, uncontrolled.
Plan:
Initiate diuretic therapy (Furosemide 40 mg IV).
Optimize antihypertensive therapy with beta-blockers.
Tight glucose control with insulin as per sliding scale.
Continuous cardiac monitoring.
Follow-up echocardiogram to assess cardiac function.
Consult cardiology for further evaluation and management.
Follow-up:
Monitor closely for improvement in symptoms and adjust treatment as needed.
Attending Physician:
Dr. [Your Name], MD
Date: October 2, 2094
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