Clinical Presentation & Protocol
Patient Usually Complains Of
Patient presents for routine follow-up of HFrEF (LVEF [XX]%). Patient remains asymptomatic with no limitations of physical activity. Denies dyspnea, orthopnea, PND, or peripheral edema. Current functional status classified as NYHA Class I. Adherent to GDMT.
Clinical Examination Findings
General: Patient in no acute distress, comfortable at rest. CV: Regular rate and rhythm, S1/S2 present, no S3/S4 or murmurs. JVP normal, no hepatojugular reflux. Lungs: Clear to auscultation bilaterally, no crackles or wheezing. Extremities: No peripheral edema, pulses 2+ symmetric.
Treatment Protocol
Continue GDMT: [Beta-blocker: Dose], [ARNI/ACEi/ARB: Dose], [MRA: Dose], [SGLT2i: Dose]. Monitor electrolytes, renal function, and BP. Maintain sodium restriction (<2g/day) and fluid management. Follow-up in [X] months with repeat TTE as indicated.