[doctor] hi frank how are you i heard the medical assistant told me that you're having some shortness of breath
[patient] i am i am i am okay i am not great
[doctor] you are okay you are not great okay well how long have you been having some shortness of breath
[patient] it's been about a week
[doctor] it's been about a week okay now have you ever experienced these symptoms before
[patient] yeah this happened about six months ago and i came in and they changed my lasix dose and i seemed to get better
[doctor] okay alright so let's talk a little bit about that now i know that you have a history of coronary disease you know you had had a heart attack back in twenty eighteen we put that stent in your right coronary artery i know that the pumping function of your heart was a little low you know that what we call that ejection fraction was about thirty five percent have you been watching your salt intake
[patient] yeah but you know it's been the holidays the last couple of weeks and you know i we've had a bunch of family get togethers and i i do n't think my diet has been everything it should have been
[doctor] okay alright now have you noticed any swelling in your legs
[patient] yes definitely
[doctor] okay and are you taking the lasix now i know that we had increased it to about forty milligrams once a day are you taking it
[patient] yeah i take it everyday
[doctor] you take it everyday okay do you notice that you're urinating any less recently
[patient] no it seems about the same
[doctor] okay
[patient] you know i i urinate at night you know at least once sometimes twice a night that's a little more it happened before
[doctor] okay alright and do you feel short of breath at rest or is it mostly when you're just walking around
[patient] walking around stairs in particular walking quickly
[doctor] okay and how about when you're sleeping at night are you able to lay flat or do you have to sit up a little bit
[patient] i gone from one pillow to two pillows
[doctor] okay alright and do you ever wake up really short of breath does it ever wake you up
[patient] it did that six months ago it has not done that so far this time
[doctor] okay alright now tell me a little bit about when was the last time you saw your nephrologist
[patient] about about a month ago
[doctor] okay because as you know you know we we do talk about the fact that you have some kidney dysfunction about stage three so it's gon na be important for you to continue to follow up with your kidney doctor now are you how are you doing staying away from things like motrin and advil i know that you had had some knee pain in the past and you know how are you doing staying away from those medications
[patient] yeah everybody has told me not to use it so i do n't except when i have pretty bad pain i had an episode about a week ago some pain in my feet actually and i i had to take motrin to get rid of it so yeah i took motrin for a while and i stopped as quickly as i could
[doctor] okay now are you able to take tylenol do you not feel any relief from tylenol when you take it
[patient] yeah tylenol's lovely it just is not very effective
[doctor] okay alright yeah because i think we really want you to stay away from that those anti-inflammatories because that can make your kidney function worse and obviously you know we do n't wan na see you go on dialysis or anything like that so we'll have
[patient] mean neither
[doctor] right so we'll have to you know really work on that now tell me a little bit about are you watching the potassium and stuff in your diet
[patient] nobody's really talked to me about that so
[doctor] okay yeah so you want
[patient] i did n't know what high potassium foods are
[doctor] okay i'm sorry i've never talked to you about that in the past i that's my fault so yeah so you wan na make sure you stay away from things like bananas oranges you know potatoes have lots of potassium that type of thing and so you know because with your kidney function you know that can cause your potassium levels to go up because you do n't get rid of the potassium as you should you know
[patient] something to eat
[doctor] what's that
[patient] is there anything left is there anything left over that i ca n't eat
[doctor] so yeah you can eat you know how about this how about we give you a a referral to a dietitian and they can help you with that
[patient] sounds good
[doctor] now are you watching the nba playoff should i or should i not bring that up i is that a sensitive subject i mean i'm a self expand and and we did sweep the nuts so
[patient] yeah well i mean that's fan and i could n't sleep last night but you know
[doctor] okay well maybe we should n't talk about
[patient] kinda used to it you know where they where the favorite to win and then like that
[doctor] yeah i know i i i will say i think jason tatum and jaylen brown paid played phenomenally so i do think that they help with the cell fix over the edge so but that's all we'll talk about that what's that
[patient] i said yeah too bad they did
[doctor] yeah alright well i wan na just go ahead and do a quick physical exam on you okay so you know looking at your vital signs here in the office you know your your blood pressure is about one thirty five over eighty so it's it's not too bad and maybe like to see it a little bit lower i'm just gon na be calling out my physical exam findings and i'm gon na let you know what they mean when i'm done okay so on your neck exam i appreciate some jugular venous distention up to about nine centimeters there are no carotid bruits on your lung exam i do appreciate bibasilar crackles with occasional rhonchi that clears when you cough on your heart exam i do appreciate a three out of six systolic ejection murmur heard at the left base and on your lower extremity exam i do appreciate one to two plus pitting edema bilaterally so frank what does that mean all that means is that you have findings on you that suggest that you're retaining fluid now we'll have to talk a little bit about how we're going to address that okay so i wan na just go over a little bit about my assessment and my plan for you okay so for the for your first problem of your shortness of breath i do believe you're having a an acute heart failure exacerbation so i wan na go ahead and increase your lasix from forty milligrams a day to eighty milligrams a day and i want you to call me in two days and let me know how your weight has been with increasing the diuretic now if you start to have worsening shortness of breath before that i want you to yeah call me we may have to admit you to the hospital for some intravenous diuretics okay i also wan na go ahead and just obtain
[patient] salt on lasix all at once am i take it all at once or do i divide it up
[doctor] how about you start taking the the increased dose in the morning and then we'll see how you do and if necessary i'll have to add a second dose in the afternoon that you can take around four o'clock in the afternoon i do n't want you to take it too late at night because then you will be going to the bathroom all night okay
[patient] that sounds correct
[doctor] so i also want to go ahead and order a chest x-ray just to make sure that we are not missing anything else okay for your second problem of your coronary artery disease you know it sounds like you're doing well except for this heart failure exacerbation so i wan na go ahead and order another echocardiogram to check out that heart murmur that i hear on your physical exam just to make sure that that's not getting any worse and to make sure that the pumping function of your heart is stable and i'm gon na go ahead and call doctor white and let them know that i want you to be seen by them okay okay and then for your third problem of your stage three chronic kidney disease i want you to go ahead and try to you know do n't please do n't take anymore motrin or advil i do want you to try to stick with tylenol and if you're still having a significant problem with with some pain i want you to call me and we'll talk about some alternative medications that we can use or therapies okay i will also want to go ahead and order a complete metabolic panel just to make sure that your kidney function is stable does that sound okay
[patient] that sounds good do you have any idea what was going on with my foot pain before
[doctor] well how long have you been having it how long you've been having that foot pain
[patient] that's why i took the motrin it lasted you know four five days slowly went away
[doctor] it was in both of your feet
[patient] one
[doctor] one and where in your foot was was it
[patient] just in front of the big toe
[doctor] just in front of the big toe okay have you ever had a history of gout
[patient] nobody has told me about that
[doctor] okay alright well it sounds like it could've been gout you know with your chronic kidneys chronic kidney disease it it's a possibility so for this possible gout flare for your fourth problem of your possible gout flare let's go ahead i wan na just go ahead and order a uric acid just to see and it's something that we can talk about there is an alternative medication that you can take with your kidney function that that would n't hurt it that would n't injure it any further and i think it would work just the same
[patient] okay
[doctor] okay any other questions
[patient] just as long as you think i'm gon na get better
[doctor] i think you're gon na get better yes i think we're gon na you know i really want you to watch your salt intake and i'm gon na go ahead and order that dietary dietitian referral so that you can get your diet under control but you really have to watch your salt intake i think that that's kind of what this heart failure exacerbation is about maybe a little dietary indiscretion
[patient] okay
[doctor] okay anything else
[patient] yeah no that's good thank you
[doctor] okay you're welcome bye

Medical orders:
description: chest x-ray x-ray
order_type: imaging
reason: to make sure that we are not missing anything else
description: heart echocardiogram
order_type: imaging
reason: three out of six systolic ejection murmur heard at the left base
description: lasix milligrams eighty add a second dose in the afternoon that you can take around four o'clock in the afternoon
order_type: medication
reason: acute heart failure exacerbation
description: complete metabolic panel
order_type: lab
reason: kidney dysfunction about stage three
description: uric acid
order_type: lab
reason: possible gout flare
description: lasix milligrams once a day eighty in the morning
order_type: medication
reason: acute heart failure exacerbation