CONGESTIVE HEART FAILURE

CHF





HEART FAILURE WORK SHEET

HPI:
Document the Following:

-History of CAD / MI / PCI / CABG?
-If so, list what symptoms they presented with (CP? SOB?) , what hospital they went to, what work did they have (TTE? Cath?)

-History of Afib?:
-How did they present? How was it diagnosed?
-What symptoms do they have from Afib? (LH/dizziness, palpitations, racing heart rate sensation, syncope, pre-syncope, chest pain, dyspnea, fatigue, CHF etc)
-How were they treated? (Ever have a DCCV? Placed on any AAD or anticoagulation?)

-History of Pacemakers / ICD / CRT-D Device?
-What happened? How did they present? To what hospital?


-History of Present Illness: List symptoms they presented with (Dyspnea, DOE, LE Edema, Orthopnea, PND, weight gain etc)
***It is CRITICAL to try to determine why they have Heart Failure**

F - Forgot Medications (non-compliance)

A - Arrhythmia

A - Anemia

I - Ischemia / Iron Overload / Infection

L - Life Style (increased Na+ intake = dietary indiscretions)

U - Upregulators (Thyroid Disease, Pregnancy)

R - Rheumatic Valve Disease (Valvular Heart Disease)

E - Emboli (Pulmonary Embolism)


-History of Present Illness: List symptoms they presented with (Dyspnea, DOE, LE Edema, Orthopnea, PND, weight gain etc)

ASSESSMENT & PLAN:
1. CHF (New onset / Acute on Chronic / Systolic / Diastolic / Combined systolic & diastolic Heart Failure
-They have CHF as evidenced by (list subjective findings + Physical Exam findings + Lab data)
Subjective findings:
-Dyspnea
-Orthopnea
-PND
-LE Swelling
-Wt Gain

Clinical findings:
-JVD
-Rales
-Edema

Objective Findings:
-Elevated BNP
-CXR

***Please note that the Differential Diagnosis of Dyspnea is more than just “CHF” --> please make sure to have gone through a thorough consideration of the differential diagnosis of dyspnea. IE: if you make the argument that someone has a CHF exacerbation and they do NOT have subjective findings, clinical findings, or objective findings, have you really made a strong/compelling argument for CHF?”



-Etiology of CHF exacerbation at this point is most likely: (go through FAAILURE and try to determine why they went into CHF)
-Medical Therapy for this patient includes (List what CHF medications the patient is on, and if you want to change or make any additions to it)