Sinai-Grace Internal Medicine Residency
Ambulatory Clinic Documentation Guides
Congestive Heart Failure
·
History
- Ask
for symptoms of SOB, PND, chest pain, weight gain and orthopnea
- Any
change in exercise tolerance or level of activities due to symptoms?
Current NYHA Class.
- Check
medication compliance and verify dosage.
- Pt
following fluid restricted/2gm sodium or diabetic diet.
- Any
recent admissions for CHF exacerbation?
- Systolic
or diastolic heart failure?
- Check
if the cause of heart failure was evaluated?.
- IHD,
Valvular HD, Cardiomyopathies,
High output states, Chronic arrhythmias.
- Assess
risk factors like HTN, DM, CAD, and ETOH etc.
- Last
2D Echo results?
o
Pt follows at
heart failure clinic?
- Vaccinations
and smoking cessation.
·
Physical exam
- Vitals-BP, HR, RR, Weight
- Neck-JVD, carotid bruit
- Heart-PMI, thrills, murmurs, and
heart sounds, gallops, S3, S4, parasternal
heaves.
- Lungs- fluid overload
- Abdomen-ascites,
hepatomegaly, pulsatile
liver, hepatojugular reflex
- Pedal edema
- Peripheral pulses, other types of
pulses specific for aortic regurgitation, aortic stenosis
etc.
·
Follow up
o
Medications- ACE inhibitors/ARBs,
B-blockers, diuretics, digoxin, Isosorbide
dinatrate, hydralazine, Spironolactone and Coumadin.
Check if indicated and whether pt is on the medication.
o
Optimize medications for
BP/Diabetes/Hypercholesterolemia
o
Stress to patient compliance with medication and refills and diet
o
Referral to HF
clinic if indicated
·
Investigations
o
Serum Cr, Hb, TSH and Serum K level
o
2 D echo if
indicated
o
EKG-baseline