Clinical Presentation & Protocol
Patient Usually Complains Of
Patient presents for follow-up of HFrEF (Stage C). Reports [stable/worsening] dyspnea on exertion, orthopnea, and paroxysmal nocturnal dyspnea. Current NYHA functional class [I/II/III/IV]. Denies chest pain, palpitations, or syncope. Adherence to GDMT and low-sodium diet is [good/poor]. Weight fluctuations noted at [X] kg over the last week.
Clinical Examination Findings
Vitals: BP [X/X], HR [X], O2 sat [X%]. General: Patient appears [well-appearing/distressed]. CV: JVD noted at [X] cm above sternal angle. PMI displaced. Regular rate and rhythm, S1/S2 present, S3 gallop appreciated. No murmurs. Lungs: Bilateral crackles at bases, diminished breath sounds. Extremities: [1+/2+/3+] pitting edema to the [ankles/knees]. Peripheral pulses [intact/diminished].
Treatment Protocol
Continue GDMT: [Beta-blocker] [Dose], [ARNI/ACEi/ARB] [Dose], [MRA] [Dose], [SGLT2i] [Dose]. Diuretic titration: [Furosemide/Bumetanide] [Dose] [frequency]. Monitor electrolytes and renal function. Advise daily weights and strict sodium restriction (<2g/day). Follow-up in [X] weeks.