Sinai-Grace Internal Medicine Residency Ambulatory Clinic Documentation Guides
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.
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.
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.