Clinical Presentation & Protocol
Patient Usually Complains Of
Patient presents with exertional dyspnea (NYHA Class II) and fatigue. Reports occasional orthopnea and mild peripheral edema. No history of paroxysmal nocturnal dyspnea or chest pain. Symptoms are stable but limiting physical activity. Known history of hypertension and diastolic dysfunction.
Clinical Examination Findings
Cardiovascular exam reveals regular rate and rhythm, S1 and S2 present, S4 gallop noted. No murmurs, rubs, or gallops. JVP is 6 cm H2O. Lungs are clear to auscultation bilaterally. Extremities show 1+ pitting edema to the ankles. BMI is [insert value].
Treatment Protocol
Initiate SGLT2 inhibitor therapy (e.g., Empagliflozin 10mg daily). Optimize blood pressure control with ACE inhibitor or ARB. Diuretic therapy (e.g., Furosemide 20mg PRN) for symptomatic fluid management. Emphasize strict sodium restriction (<2g/day) and daily weight monitoring.