CHF follow-up
Age: years old
Gender:
HISTORY:
Returns for a congestive heart failure follow-up
Last visit was ago
Progress since last visit:
Current symptoms:
, , , ,
,
, over
Smoking: , pack-years
Alcohol: , drinks per
Recreational drugs: ,
Caffeine: daily
Diet: , , , ,
Physical activity:
Weight: ,
Impact on daily activities:
Overall quality of life:
Cardiac rehabilitation program:
ECG:
Echocardiogram:
Stress test:
Coronary angiogram:
Medications
, , , , , , ,
Adherence: ,
Vaccinations:
Pneumococcal:
Influenza:
Covid:
EXAM:
General appearance: ,
Vital signs: , BP , HR , RR , SpO2 %, Temp °
Metrics: weight: , height: cm, waist: cm, BMI:
Neck: , , , c-spine
Heart: , ,
Lungs: , ,
Extremities: , , cap refill sec, pulses , ,
ASSESSMENT:
DDx: congestive heart failure, HFpEF, HFrEF, right heart failure, left heart failure, valvular heart disease, arrhythmias, hypertension, ischemic heart disease, cardiomyopathies, thyroid disorders, renal insufficiency, volume overload, medication noncompliance, dietary noncompliance, sleep apnea, pulmonary hypertension, chronic lung disease
PLAN:
Investigations:
- Blood work: , , , , ,
- Chest X-ray
- ECG
- Echocardiogram
- Home blood pressure monitoring
Treatments:
- Lifestyle counseling: , , , ,
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-
-
-
-
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Further care:
- Referral to cardiologist
- Referral to cardiac rehabilitation program
- Follow-up in
- Return if symptoms worsen or if new symptoms develop such as chest pain, shortness of breath, or fainting
- Referral to ER if severe chest pain, severe shortness of breath, or fainting occurs
HISTORY: EXAM: ASSESSMENT: PLAN: