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

Items in BOLD should be addressed every visit.