Initial Evaluation (or new patient to you/practice)

Chronic Heart Failure Epic Smart Text

I. History

.name is a .age male/female presenting today for: Establishing care for known CHF / Follow up of known CHF / Possible signs and symptoms of CHF / * (If previous known dx, details of eval, hospitalization and treatment): *

Current relevant ROS: (class 1 rec by ACC/AHA) General: fatigue, decreased concentration or memory, insomnia Cardiopul: chest pain, SOB, DOE, orthopnea, PND, edema GU: oliguria, nocturia GI: Abdominal distension, N/V

PMH: Risk factors for underlying causes: Htn, CAD/angina, MI, DM, congenital/valvular dz Other CV risk factors: lipids, CVA, PVD Risk factors for precipitating causes: Anemia, thyroid dz, renal dz, COPD, Renal dz.

PSH: cardiac surgeries, catheterization, angioplasty

FH: CV dz, sudden death, early death CV event

Medications (including all otc, herbals, etc)

Habits: tobacco, etoh, illicit drugs Lifestyle: diet - sodium, fats, salt Level usual activity, exercise

II. Physical Exam

General: .vs. Neck: presence of JVD, abdominojugular reflex, thryomegaly, carotid bruits Cor: gallops, murmurs, rubs Lungs: presence of rales, wheezes, rubs Abd: hepatomegaly, ascites Ext: pedal edema, pulses, warm/cool to touch

III. Lab / Imaging

Class 1 recommendations per AHA / ACC - should have baseline: Cbc, UA, chem. 18 (lytes, BUN/Scr, LFT’s), TSH (if unexplained, ferritin, ANA) ECG CXR Echo (if unexplained - consider stress echo, stress imaging, if hx angina, cath vs stress imaging)

IV. Assessment

Type: diastolic vs systolic AHA class: (A,B,C,D) NYHA fx class (1,2,3,4) Compensated vs uncompensated

V. Management

1. Non pharmacologic Diet: sodium restriction. (Calorie restriction/wt loss if overwt) Habit/Lifestyle modifications Tobacco cessation, modest etoh, no illicit drug use Activity recommendations

2. Pharmacologic - Systolic dysfx ACEI - (class 1 rec ACC/AHA for all w/ hx of systolic dysfx, or prev MI) Diuretic (class 1 rec if hx/evidence fluid overload) Betablocker (class 1 rec if prev MI, hx LV dysfx but no current fluid retention)

Digoxin (class 1 rec for stage C symptomatic HF pts) Nitrates -(class IIb rec- if pulmonary venous congestion/already on ACE,BB,dig,diuretic) Spironolactone - (class IIa for NYHA class IV pts, already on ACE,BB,dig,diuretic) Hydralazine/Nit combo - same as spironolactone for pts not tolerant of ACEI or ARB

Diastolic dysfx Diuretics (class 1 rec ACC/AHA - tx pul/peripheral edema) After that: BB, CCB, ACE to minimize sx’s and tx Htn

1. Other pharmacologic recs: Treat Htn to current JNC VII recs, using ACEI, BB, diuretics as initial drugs of choice Treat lipid disorders to current recs ASA qd if underlying CAD (class IIa rec) Anticoagulation if chronic Afib (class 1 rec)

2. Pt education Review basics of dx, dz process, rx and tx goals, when to call w/ probs, watching home wts Follow up in *

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Follow up Evaluation of Chronic Heart Failure Epic Smart Text

I. History .name is a .age male/female presenting today for: Follow up of known CHF

Updates on evaluations, hospitalization or treatment since last visit: none/*

Current relevant ROS: (class 1 rec by ACC/AHA) General: fatigue, decreased concentration or memory, insomnia Cardiopul: chest pain, SOB, DOE, orthopnea, PND, edema GU: oliguria, nocturia GI: Abdominal distension, N/V

Medications: update list, including all otc, herbals, etc Compliance with prescribed regimen: good / < ideal *

Habits: tobacco, etoh, illicit drugs Lifestyle: diet - sodium, fats, salt Level usual activity, exercise

II. Physical Exam

General: .vs. Neck: presence of JVD, abdominojugular reflex, thryomegaly, carotid bruits Cor: gallops, murmurs, rubs Lungs: presence of rales, wheezes, rubs Abd: hepatomegaly, ascites Ext: pedal edema, pulses, warm/cool to touch

III. Lab

if on diuretics/ ACE - q 6 month chem. 7 if on digoxin, q 6 - 12 mo dig level

IV. Assessment

Type: diastolic vs systolic AHA class: (A,B,C,D) NYHA fx class (1,2,3,4) Compensated vs uncompensated

V. Management

1. Non pharmacologic - review Diet: sodium restriction. (Calorie restriction/wt loss if overwt) Habit/Lifestyle modifications Tobacco cessation, modest etoh, no illicit drug use Activity recommendations

2. Pharmacologic - Systolic dysfx ACEI - (class 1 rec ACC/AHA for all w/ hx of systolic dysfx, or prev MI) Diuretic (class 1 rec if hx/evidence fluid overload) Betablocker (class 1 rec if prev MI, hx LV dysfx but no current fluid retention)

Digoxin (class 1 rec for stage C symptomatic HF pts) Nitrates -(class IIb rec- if pulmonary venous congestion/already on ACE,BB,dig,diuretic) Spironolactone - (class IIa for NYHA class IV pts, already on ACE,BB,dig,diuretic) Hydralazine/Nit combo - same as spironolactone for pts not tolerant of ACEI or ARB

Diastolic dysfx Diuretics (class 1 rec ACC/AHA - tx pul/peripheral edema) After that: BB, CCB, ACE to minimize sx’s and tx Htn

1. Other pharmacologic recs: Treat Htn to current JNC VII recs, using ACEI, BB, diuretics as initial drugs of choice Treat lipid disorders to current recs ASA qd if underlying CAD (class IIa rec) Anticoagulation if chronic Afib (class 1 rec)

2. Pt Ed Review compliance issues, tx goals Follow up in *

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