Clinical Presentation & Protocol
Patient Usually Complains Of
Patient presents for follow-up of HFimpEF (previously HFrEF). Baseline LVEF was [X]% with current LVEF improved to [Y]% on [Date]. Patient reports [stable/improved] functional status, NYHA class [I/II/III/IV]. Denies orthopnea, PND, or peripheral edema. Medication adherence is [good/poor]. Current GDMT includes [list meds].
Clinical Examination Findings
General: Patient is in no acute distress. CV: Regular rate and rhythm, S1/S2 audible, no murmurs, rubs, or gallops. JVP is [normal/elevated]. Lungs: Clear to auscultation bilaterally, no crackles or wheezes. Extremities: No peripheral edema, pulses 2+ bilaterally. Weight is [X] kg, stable since last visit.
Treatment Protocol
Continue current GDMT: [Beta-blocker], [ARNI/ACEi/ARB], [MRA], and [SGLT2i]. Monitor electrolytes and renal function. Maintain strict sodium restriction (<2g/day) and fluid management. Repeat TTE in [X] months to monitor LVEF stability. Advise patient to maintain current medication regimen despite improved EF to prevent relapse.