Congestive Heart Failure follow-up

Age: ‍ years old

Gender: ‍malefemale



HISTORY:

Returns for a congestive heart failure follow-up

Last visit was ‍ ‍months ago

Progress since last visit: ‍unchangedimprovedworsenedvariable in intensityresolved



Current symptoms:

‍chest pain, ‍retrosternal, ‍aching, ‍on exertionat restwith deep breath, ‍mild

‍shortness of breath

‍fatigue

‍decreased exercise tolerance

‍dizziness

‍palpitations

‍syncope

‍lower extremity edema, ‍rightleftsymmetrical

‍weight gain, ‍ ‍lbskg over ‍ ‍weeksmonths

‍orthopnea

‍paroxysmal nocturnal dyspnea



Smoking: ‍neversmokerformer smoker, ‍ pack-years

Alcohol: ‍nonesociallyexcessive, ‍ drinks per ‍dayweek

Recreational drugs: ‍none ‍cannabis, ‍IVDU

Caffeine: ‍ daily



Diet: ‍goodaveragepoor, ‍high in salt, ‍high in carbs, ‍high in fat, ‍vegan

Physical activity: ‍adequateaveragesedentary

Weight: ‍ ‍lbskg, ‍gainunchangedloss



Impact on daily activities: ‍minimalmoderateseveredebilitating

Overall quality of life: ‍goodaveragepoor ‍

Cardiac rehabilitation program: ‍completedenrolledabandonednot interested ‍



ECG: ‍ ‍normal

Echocardiogram: ‍ ‍unremarkable

Stress test: ‍ ‍normal

Coronary angiogram: ‍ ‍normal



Medications

‍Aspirin, ‍clopidogrel, ‍statins, ‍Beta blockers, ‍ACE inhibitors, ‍ARBs, ‍Calcium channel blockers, ‍Nitrates

Adherence: ‍goodaveragepoor, ‍adverse effects



Vaccinations:

Pneumococcal: ‍up-to-dateincompleteunvaccinated

Influenza: ‍up-to-dateincompleteunvaccinated

Covid: ‍up-to-dateincompleteunvaccinated





EXAM:

General appearance: ‍well-appearing, ‍apparent distress

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

Metrics: weight: ‍ ‍kglbs, height: ‍ cm, waist: ‍ cm, BMI: ‍

Neck: ‍normal, ‍lymphadenopathy, ‍, c-spine ‍

Heart: ‍RRR, ‍MRG, ‍normal S1 and S2

Lungs: ‍clear bilaterally, ‍abnormal sounds, ‍retractions

Extremities: ‍warm, ‍dry, cap refill ‍< 3> 3 sec, pulses ‍intact, ‍edema ‍bilaterally, ‍





ASSESSMENT:

‍Heart failure ‍stable

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: ‍CBC, ‍lytes, ‍creatinine, ‍BNP, ‍TSH, ‍LFTs

- Chest X-ray

- ECG

- Echocardiogram

- Home blood pressure monitoring

Treatments:

- Lifestyle counseling: ‍low sodium diet, ‍weight loss, ‍exercise, ‍smoking cessation, ‍alcohol moderation

- ‍ ‍Furosemide

- ‍ ‍Spironolactone

- ‍ ‍Beta-blockers

- ‍ ‍ACEs

- ‍ ‍ARBs

- ‍ ‍Sacubitril/Valsartan

Further care:

- Referral to cardiologist

- Referral to cardiac rehabilitation program

- Follow-up in ‍ ‍daysweeks

- 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