DATE OF SERVICE: MM/DD/YYYY
SUBJECTIVE: The patient is here today with her son due to persistent dyspnea on exertion. She notes that she is able to do only minimal activity before she begins coughing and wheezing and notices shortness of breath. Even as little as bending over to tie her shoes will precipitate her feeling of shortness of breath. She does have wheezing as well. This has been persistent now for the past three to four months.
PAST MEDICAL HISTORY: Hypertension, congestive heart failure, hypothyroidism, anxiety, and depression.
REVIEW OF SYSTEMS: Psychologic: The patient becomes very frustrated and somewhat tearful about her inability to do things. She notes that she is sensitive to any situation that may impact her sense of self worth. She has been like that for many years. She was on Pamelor years ago with reasonably good results. Her current medication, Paxil, does not seem to be that effective in controlling her current symptoms. Musculoskeletal: The patient has recently undergone carpal tunnel surgery. Cardiovascular: She denies dyspnea on exertion, orthopnea or PND. She notes no chest pain. She does note some fluid accumulation in her lower legs and will use compression stockings to combat this. Dermatologic: The patient recently underwent multiple skin biopsies. She has one lesion on her right chin, which has become slightly erythematous; she would like to get this checked.
OBJECTIVE: On ambulating up and down the hallway, she became audibly wheezy. Pulse oximetry is 96% after walking on room air. HEENT: Unremarkable. Neck: Supple without adenopathy. Lungs: Reveal scant wheezing. Extremities: Show no edema. Skin: There is a slightly erythematous oozing biopsy site on the lower right chin. This is dressed with a Band-Aid. Neurologic: The patient became somewhat teary-eyed when talking about her anxiety and depression.
ASSESSMENT:
1. Dyspnea secondary to exertional or exercise-induced asthma.
2. History of congestive heart failure.
3. Dependent edema.
4. Anxiety and depression.
PLAN: The patient wishes not to have a chest x-ray done to assess her fluid status and potential congestive heart failure. She will instead begin Dyazide one tablet every other day. She will keep her chin wound clean and dry until healed. She will taper her Paxil to every other day for one week and then twice a week for one week.
She will follow up in two to three weeks regarding her depression. She is also to begin Advair 100/50 mcg one puff twice a day for her exercise-induced asthma. She will be reassessed in two to three weeks. Of note, blood pressure today was 112/72.
