Letter to GP

GP Address

Dear Colleague

Re: Mr Sipho Ndlovu, DOB: 14/05/1962

Thank you for referring this 61-year-old retired accountant who presented today with progressive exertional dyspnoea and bilateral ankle oedema.

Mr Ndlovu reports a 3-month history of worsening SOB on exertion, now occurring after walking 100 m on the flat (NYHA Class III). He notes two-pillow orthopnoea and occasional PND over the past fortnight, alongside progressive ankle swelling. He denies chest pain, palpitations, or syncope. PMH is significant for HPT and T2DM. Current medications include amlodipine (Norvasc®) 10 mg PO OD and metformin (Glucophage®) 1,000 mg PO BID. He is an ex-smoker (20 pack-years, quit 2010) and consumes minimal alcohol.

On examination, he was comfortable at rest, BP 148/88 mmHg, HR 86 bpm (regular), SpO2 95 % on room air, and temp 36.7 °C. JVP was elevated at 4 cm above the sternal angle. Auscultation revealed a displaced apex beat in the 6th intercostal space, an S3 gallop, and bibasal inspiratory crackles. There was pitting oedema to the mid-shins bilaterally.

We discussed a likely diagnosis of newly decompensated congestive cardiac failure, secondary to hypertensive or ischaemic heart disease. I explained the need for baseline investigations, including an urgent echocardiogram, ECG, CXR, FBC, U&E, and NT-proBNP. We also discussed lifestyle modifications, specifically fluid restriction (1.5 L/day), daily weight monitoring, and a low-sodium diet.

I have initiated furosemide (Lasix®) 40 mg PO OD and enalapril (Pharmapress®) 5 mg PO BID, while discontinuing his amlodipine. I counselled him on potential adverse effects, including postural hypotension, dizziness, and renal impairment, and advised a repeat U&E in 10 days. He is scheduled for an outpatient transthoracic echocardiogram on 24/05/2024 and will return to my clinic in 2 weeks for review. He was advised to present to the emergency department immediately if he experiences resting dyspnoea or chest pain.

Yours faithfully,

Dr Pieter van der Merwe Specialist Physician (Internal Medicine)