Date:
Patient:
MRN:
Clincian: (Cardiologist)
Reason for Visit:
Follow-up for heart failure (HF)
Evaluation of symptoms (shortness of breath, fatigue, edema)
Review of laboratory and imaging results
Assessment of response to treatment and disease management
History of Present Illness:
Briefly describe the patient’s current status:
Severity and frequency of symptoms (shortness of breath, fatigue, exercise intolerance)
Changes in weight or fluid retention (edema)
Response to previous treatment approaches (medications, lifestyle modifications)
Past Medical History:
Underlying cause of heart failure (ischemic cardiomyopathy, valvular heart disease, etc.)
Previous hospitalizations for HF decompensation
Comorbid medical conditions (diabetes, hypertension, chronic kidney disease)
Social History:
Smoking history (significant risk factor)
Alcohol or illicit drug use
Dietary habits and physical activity level
Family History:
Family history of heart disease
Physical Exam:
Vital Signs:
Elevated blood pressure may be present.
Respiratory rate may be increased with shortness of breath.
Consider mentioning jugular venous distention (JVD) on exam if present.
Cardiovascular exam:
Assess for heart murmurs suggestive of valvular disease.
Listen for lung crackles indicative of pulmonary edema.
Evaluate for peripheral edema (swelling in legs or ankles).
Labs:
BNP (B-type natriuretic peptide) or NT-proBNP: Levels may be elevated in heart failure.
Electrolytes (potassium, sodium) to monitor for imbalances with diuretics.
Kidney function tests (creatinine, BUN) to assess for potential kidney dysfunction.
Consider mentioning other labs ordered as needed (thyroid function tests, complete blood count)
Imaging:
Chest X-ray: May show signs of pulmonary edema (fluid in the lungs).
Echocardiogram: The gold standard for evaluating heart function, valve structure, and chamber size.
Consider mentioning other imaging studies ordered as needed (CT scan, MRI) for specific diagnostic purposes.
Assessment:
Summarize the diagnosis, cause of HF (if known), and disease severity (New York Heart Association [NYHA] functional class).
Evaluate the effectiveness of current treatment based on symptom control, weight management, and laboratory results.
Plan:
Outline the treatment plan based on the assessment:
Medication management:
Diuretics: Cornerstone of therapy for volume overload.
ACE inhibitors/ARBs: Vasodilators to improve blood flow and reduce workload on the heart.
Beta-blockers: Slow heart rate and decrease oxygen demand.
Consider mentioning other medications used for specific situations (anticoagulants, MRA antagonists).
Lifestyle modifications:
Dietary changes (salt restriction, weight management)
Smoking cessation
Regular exercise program tailored to individual limitations
Reiterate the importance of medication adherence and following recommended lifestyle changes.
Consider mentioning referral for cardiac rehabilitation if appropriate.
Prognosis:
Briefly discuss the prognosis. Heart failure is a chronic progressive condition, but early diagnosis and treatment can improve symptoms, quality of life, and survival.
Emphasize the importance of ongoing monitoring, medication adherence, and healthy lifestyle modifications to manage the condition and prevent worsening.
Education:
Document any education provided to the patient regarding:
The nature of heart failure, its cause, and risk factors
The importance of medication adherence and following dietary/exercise recommendations
Warning signs and symptoms of worsening heart failure (increased shortness of breath, weight gain, edema)
The benefits of cardiac rehabilitation and support groups for patients with heart failure
Notes:
Include any additional relevant information not covered above, such as the patient’s understanding of their condition and treatment plan, and any concerns they may have about medication side effects, activity limitations, or the emotional impact of chronic illness.
Consider the patient’s emotional well-being and offer support or referral for mental health services if needed.
Disclaimer: This is a template and should be adapted to the specific needs of each patient. It is important to consult with a cardiologist for diagnosis, treatment recommendations, and prognosis.