Clinical Presentation & Protocol
Patient Usually Complains Of
Patient presents with severe symptoms of heart failure at rest. Reports dyspnea at rest, orthopnea requiring [number] pillows, and paroxysmal nocturnal dyspnea. Significant fatigue, exercise intolerance, and recent weight gain of [number] kg. Symptoms refractory to current GDMT. No chest pain or palpitations reported.
Clinical Examination Findings
General: Patient appears distressed, tachypneic at rest. Vitals: BP [value], HR [value], SpO2 [value] on [O2 support]. CV: JVD present to [level] cm H2O, displaced PMI, S3 gallop audible, holosystolic murmur at apex (mitral regurgitation). Lungs: Bilateral crackles extending to [level] of lung fields. Extremities: 3+ pitting edema to mid-thigh, cool peripheries, delayed capillary refill.
Treatment Protocol
Immediate management: 1. Optimize diuretics (IV furosemide/bumetanide). 2. Titrate GDMT (ARNI/ACEi, Beta-blocker, MRA, SGLT2i) as tolerated. 3. Consider inotropic support (milrinone/dobutamine) if cardiogenic shock suspected. 4. Fluid restriction (<1.5L/day) and sodium restriction (<2g/day). 5. Evaluate for advanced therapies (LVAD, heart transplant, or palliative care).