Patient: [Patient Name]
MRN: [Medical Record Number]
Date: [Date of Encounter]
Chief Complaint:
New or follow-up for mitral regurgitation (MR)
(Specify) Symptoms may be absent in early stages.
With worsening MR: fatigue, shortness of breath (particularly with exertion), palpitations, chest pain (less common).
History of Present Illness:
Onset, duration, and severity of symptoms.
Functional limitations due to symptoms (e.g., exercise intolerance).
For established MR:
Progression of symptoms.
Response to previous treatment (medications, procedures).
Past Medical History:
Underlying conditions that may have caused MR:
Myocardial infarction (heart attack)
Ischemic heart disease (coronary artery disease)
Dilated cardiomyopathy
Rheumatic fever (less common)
Congenital heart defects (e.g., mitral valve prolapse)
Risk factors for underlying heart disease:
Hypertension
Diabetes
Hyperlipidemia (high cholesterol)
Smoking history
Medications:
List all current medications, including heart medications (diuretics, beta-blockers).
Social History:
Smoking history (risk factor for underlying heart disease).
Family History:
Family history of heart disease (may increase risk).
Physical Exam:
Vital signs: Assess for tachycardia (rapid heart rate), tachypnea (rapid breathing), and elevated jugular venous pressure (JVD) in severe cases.
Cardiovascular exam:
Listen for a murmur characteristic of MR.
Assess for rales (crackles) in the lungs (fluid buildup with severe MR).
Assess for peripheral edema (fluid retention in legs) in severe cases.
Laboratory Tests:
Complete blood count (CBC) may be normal.
Basic metabolic panel (BMP) may reveal electrolyte abnormalities with severe heart failure.
Brain natriuretic peptide (BNP) levels may be elevated with heart failure.
Imaging Studies:
Chest X-ray: May show cardiomegaly (enlarged heart) and pulmonary edema (fluid in lungs) in severe cases.
Electrocardiogram (ECG): May show atrial fibrillation (irregular heart rhythm) which can worsen MR.
Echocardiogram: The definitive test for diagnosing MR. It assesses the severity of regurgitation, valve anatomy, and left ventricular function.
Assessment:
Mitral regurgitation: Based on clinical presentation (symptoms, physical exam findings), echocardiogram results, and presence of underlying cause.
Severity of MR: Echocardiogram classifies MR severity (mild, moderate, severe) based on the degree of blood flow back into the left atrium.
Left ventricular function: Echocardiogram also assesses left ventricular ejection fraction (LVEF) to determine how well the heart is pumping blood.
Cause of MR: Identify the underlying condition that caused the mitral valve to become incompetent.
Plan:
Treatment depends on the severity of MR and left ventricular function:
Asymptomatic or mild MR: Regular monitoring with echocardiograms.
Moderate MR: Medications (diuretics, beta-blockers) to manage symptoms and improve heart function.
Severe MR with symptoms or worsening heart function: Consider surgical mitral valve repair or replacement to prevent heart failure.
Treatment of underlying cause: Address any underlying conditions that contributed to MR (e.g., coronary artery bypass surgery for severe CAD).
Lifestyle modifications: Recommend a healthy lifestyle to improve heart health, including:
Diet modifications (low-salt, low-fat diet)
Weight management
Regular exercise (as tolerated)
Smoking cessation
Follow-up: Schedule regular follow-up visits with repeat echocardiograms to monitor disease progression and treatment response. Patients with severe MR may require closer monitoring.
Consultations: Referral to a cardiologist is recommended for diagnosis, treatment planning, and management of MR, especially if surgical intervention is considered. Depending on the underlying cause, consultation with other specialists (e.g., rheumatologist for rheumatic fever) may be necessary.