Heart Failure Exacerbation

HISTORY:

‍Shortness of breathOrthopneaEdema for ‍ ‍hoursdays

‍shortness of breath

‍edema

‍fatigue

‍weight gain, ‍ ‍lbskg over ‍ ‍weeksmonths

‍decreased exercise tolerance

‍orthopnea

‍paroxysmal nocturnal dyspnea

‍cough, ‍non-productiveproductive

‍sputum, ‍clearcolored

‍wheezing

‍nausea

‍chest pain, ‍retrosternal, ‍on exertionat restwith deep breath

‍palpitations

‍dizziness

‍syncope

Worsening factors: ‍none

Treatments tried: ‍none, ‍effectiveineffective



EXAM:

General appearance: ‍well-appearing

Vital signs: ‍normal, BP ‍, HR ‍, RR ‍, SpO2 ‍ %, Temp ‍°

Neck: ‍normallymphadenopathy

Heart: ‍RRR, ‍normal S1 and S2

Lungs: ‍clearabnormal sounds, ‍retractions

Skin: ‍no rash

Extremities: ‍edema, ‍warm, cap refill ‍< 3 sec> 3 sec, pulses ‍normal, ‍



ASSESSMENT:

‍Heart failure exacerbation ‍likelysuspectedpossible

DDx: ‍



PLAN:

- Blood work: ‍CBC, ‍lytes, ‍creatinine, ‍BNP, ‍TSH, ‍LFTs

- Chest X-ray

- ECG

- Echocardiogram

- Low sodium diet

- Fluid restriction

- Regular exercise

- Smoking cessation

- Alcohol moderation

- ‍ ‍Furosemide

- ‍ ‍Spironolactone

- ‍ ‍Beta-blockers

- ‍ ‍ACEs

- ‍ ‍ARBs

- ‍ ‍Sacubitril/Valsartan

- Home blood pressure monitoring

- Referral to cardiologist

- Referral to CHF clinic

- Refferal to cardiac rehabilitation program

- Follow-up in ‍ ‍weeksmonths

- Return if symptoms worsen or if new symptoms develop such as chest pain or shortness of breath

- Go to ER if severe chest pain, severe shortness of breath, or fainting occurs