João Almeida 82 · Bed 7

Family: Lurdes Almeida (wife)

Today's chart note

DAILY PROGRESS NOTE · Internal Medicine, Ward 4B, Bed 7
João Almeida, 82M · Day 5 of admission · Sat 26 Sep 2026

PROBLEMS
1. Acute decompensated heart failure (HFrEF): active, slowly improving
2. AKI on CKD stage 3: active, stable (creatinine 1.8 from 2.1)
3. Atrial fibrillation: chronic, rate controlled

FINDINGS (last 24h)
Weight 78.3 kg (-2.1 kg in 48h). Bibasal crackles reduced. Peripheral oedema to mid-shin.
BP 108/64, HR 88 irregular, SpO2 94% on 2 L O2.
Awake, oriented, tired. Ate half of lunch.
Labs: NT-proBNP 8,400 pg/mL (from 11,200), K+ 4.1, creatinine 1.8.
Echo (24/09): LVEF 25%, severe LV systolic dysfunction.

PLAN
- Continue IV furosemide 40 mg bid, reassess Monday
- Wean O2 as tolerated
- Discharge date not yet determinable, depends on diuretic response
- LVEF 25%: prognosis and goals-of-care conversation with patient and wife in person, family meeting to be scheduled

NURSING
- Daily weight before breakfast
- Fluid restriction 1.2 L/day, strict fluid balance chart
- U&E at 07:00

Family update · AI draft

Reading today's chart note
Translating into plain language
Applying the nursing-scope rules
Holding back what only you should say

Only switched-on items are sent to Lurdes.