Last Mile Care A2A

Patient Case Intake

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DISCHARGE SUMMARY
Metro Health Medical Center
Date: March 12, 2026

Patient: Maria Elena Rodriguez
DOB: 04/12/1958 | Age: 67 | Sex: Female
MRN: MRN-20260312-4471
Visit Type: Outpatient Cardiology Follow-Up
Attending: Dr. James Whitfield, MD — Internal Medicine / Cardiology

CHIEF COMPLAINT:
Patient presents with worsening fatigue, mild lower extremity edema, and intermittent dyspnea on exertion over the past 2 weeks.

HISTORY OF PRESENT ILLNESS:
Ms. Rodriguez is a 67-year-old female with a history of congestive heart failure (CHF, NYHA Class II), hypertension, type 2 diabetes mellitus, and chronic kidney disease stage 3. She reports progressive fatigue and mild bilateral ankle swelling over the past 10-14 days. She denies chest pain, orthopnea, or paroxysmal nocturnal dyspnea. She has been compliant with her current medications but notes occasional missed doses of her diuretic.

PHYSICAL EXAMINATION:
- BP: 148/92 mmHg
- HR: 82 bpm, regular
- RR: 18/min
- SpO2: 95% on room air
- Weight: 78 kg (up 2.5 kg from last visit)
- Cardiac: Regular rate and rhythm, no murmurs
- Lungs: Bibasilar crackles, mild
- Extremities: 1+ bilateral pitting edema

ASSESSMENT:
1. Congestive heart failure — mild exacerbation likely secondary to fluid retention and intermittent diuretic non-compliance
2. Hypertension — suboptimally controlled
3. Type 2 Diabetes Mellitus — stable on current regimen
4. Chronic Kidney Disease Stage 3 — stable, monitor renal function

PLAN:
1. Increase Furosemide from 20mg daily to 40mg daily
2. Start Carvedilol 6.25mg twice daily
3. Continue Lisinopril 10mg daily
4. Continue Metformin 1000mg twice daily
5. Order BNP level and Comprehensive Metabolic Panel
6. Refer to Cardiology for echocardiogram and formal CHF management
7. Follow-up appointment within 7 days with PCP
8. Daily weight monitoring — report gain >2 lbs in 24 hours

PATIENT INSTRUCTIONS:
- Take all medications as prescribed, especially the new Furosemide dose and Carvedilol
- Weigh yourself every morning before eating
- Low sodium diet — avoid canned soups, processed foods, added salt
- Report immediately: shortness of breath at rest, chest pain, weight gain >2 lbs/day, severe swelling in legs, dizziness or fainting
- Complete lab work within 3 days
- Schedule cardiology referral within 2 weeks
- Return to clinic within 7 days

WARNING SIGNS — SEEK IMMEDIATE CARE:
- Shortness of breath at rest or worsening dyspnea
- Chest pain or chest pressure
- Weight gain greater than 2 pounds in 24 hours
- Severe leg swelling
- Dizziness, lightheadedness, or fainting
- Confusion or altered mental status

Discharge Disposition: Home
Follow-Up: PCP within 7 days, Cardiology within 2 weeks

Signed: Dr. James Whitfield, MD

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