Date: [DATE]
Patient: [Patient Name]
MRN: [Medical Record Number]
Subjective:
Briefly summarize the patient’s current symptoms.
Examples: fatigue, shortness of breath (dyspnea), chest pain, palpitations, lower extremity edema.
Note any recent changes in symptoms or functional status.
Inquire about medication adherence and any side effects.
Objective:
Vital Signs: Include heart rate, blood pressure, respiratory rate, oxygen saturation (SpO2)
Physical Exam:
General: Assess for signs of heart failure (e.g., jugular venous distention, peripheral edema, ascites)
Cardiovascular:
Heart sounds: Note presence of murmurs, S3 gallop
Pulses: Assess for jugular venous pulsation, capillary refill time
Respiratory: Evaluate for signs of pulmonary congestion (e.g., crackles)
Labs:
List any relevant labs, including electrolytes, kidney function, thyroid function, BNP (brain natriuretic peptide) levels.
Imaging:
Mention recent echocardiogram results (if available). Summarize key findings such as LVEF (left ventricular ejection fraction), chamber size, valvular function.
Assessment:
Dilated cardiomyopathy (DCM) with current New York Heart Association (NYHA) functional class [e.g., I, II, III, IV]
Consider mentioning the likely etiology of DCM (if known) – idiopathic, ischemic, etc.
If heart failure is present, mention the stage (e.g., A, B, C, D) according to the American College of Cardiology (ACC)/American Heart Association (AHA) classification.
Plan:
Medications:
List current medications for heart failure (e.g., ACE inhibitors, ARBs, beta-blockers, diuretics, MRA) with dosages.
Indicate any planned medication adjustments.
Lifestyle modifications:
Address importance of diet (low sodium), exercise recommendations, smoking cessation, and weight management.
Follow-up:
Schedule the next clinic visit.
Mention any planned investigations (e.g., repeat echocardiogram).
Note: This is a template and should be adapted to the specific patient encounter. Document all relevant information pertaining to the management of dilated cardiomyopathy and heart failure.