C10008940 / invoice 10000

10/03/2026 Reason:  check up post pulmonary infection 

History:  finished all medication, currently only on probiotic, 
no more sneezing or coughig, no discharge, but breathing slightly heavy and her resting breathing count is higher than normal, not fully back to his usual self but active,  

Vital Signs:
Temperature:  38.2C
Heart Rate:  146bpm 
Pulse rate:  144
PB: doller: 120 mmHg
Pulse character: strong and synchronous. 
Respiration Rate:mild panting . 
MM:p/m
CRT:  <2sec

Dehydration assessment: Euhydrated MM moist no skin tent

PHYSICAL EXAMINATION:
Appearance: BAR; BCS 5/5 overwight
Eyes:   wnl
Ears: nsf
Nose: nsf , no discharge 
Oral Cavity:  mild plaque and  tartar
Cardiovascular: Auscultation no murmur detected ,pulse quality normal ,rhythm regular
Respiratory: Mild tachypnea, no rale or stridor
Musculoskeletal: wnl
Neurological: no deficit 
Integument:nsf 
Peripheral LNs:Normal size, symmetrical
Urogenital:  nsf
Rectal exam: nsf

Assessment/Problem List:  slightly heavy breathing, 
Performed conscious x3 thoracic radiographs, moderate bronchial and mild interstitial pattern, cardiac silhouette looked slightly larger than it should be, 

DDx:   concerning HCM with mild pulmonary edema

Treatment:  inhouse echo performed by GM

ECHOCARDIOGRAM:
Normal cardiac structure and function. no signs of regurgitation or stenosis of major valves or vessels noted
Normal chamber measurements.

Treatment: dispensed low dose frusemide for 2 weeks

Plan: Weight loss!
Recommended recheck x-rays 4-8 weeks later (sooner if signs worsen)