Cardiac Nurse Heart Failure Template:
Reason for Visit: Patient presents for routine follow-up regarding chronic heart failure management, reporting increased fatigue and mild ankle swelling over the past week. Symptoms have been present for approximately 7 days, gradually worsening.
History of Presenting Illness:
Patient reports a gradual increase in fatigue and mild bilateral ankle oedema over the last week. Denies any acute shortness of breath at rest, but notes increased dyspnea on exertion, now occurring with walking two flights of stairs instead of three. Orthopnoea and PND remain stable, requiring two pillows. No recent changes in activity levels or diet reported. The increased fatigue impacts her ability to perform daily chores like vacuuming.
- Symptoms reviewed:
- Shortness of Breath (SOB): Increased dyspnea on exertion, now with 2 flights of stairs (previously 3). No orthopnoea or PND.
- Oedema: Bilateral pitting oedema to ankles, +1, worse at end of day, improves overnight. No redness or warmth.
- Fatigue: Increased general fatigue, impacting light household activities. Energy levels are low throughout the day.
- Dizziness on standing or at rest: Denies dizziness or syncopal episodes.
- Chest Pain/Discomfort: Denies chest pain or discomfort.
- Palpitations: Denies palpitations or heart rhythm irregularities.
- Weight Changes: Reports a weight gain of 1.5 kg over the past week, consistent with fluid retention.
- Other: No other relevant symptoms reported.
Past Medical History:
- Chronic Heart Failure with reduced Ejection Fraction (HFrEF)
- Hypertension
- Type 2 Diabetes Mellitus
- Chronic Kidney Disease Stage 3
- Hyperlipidaemia
- Cardiac History:
- Heart Failure Aetiology: Ischemic cardiomyopathy.
- Ejection Fraction (EF): 30% (documented 15 July 2024).
- Hospitalizations for HF: February 2023 for acute decompensated heart failure due to medication non-adherence. November 2022 for atypical chest pain, ruled out MI.
- Interventions (e.g., PCI, CABG, valve surgery, device implantation): PCI to LAD June 2020; ICD implanted March 2021 for primary prevention.
Medications:
Patient currently takes a range of medications for her cardiac and comorbid conditions. Adherence reported as good.
- Medication Reconciliation:
- Ramipril 5mg PO daily (for hypertension and heart failure)
- Bisoprolol 5mg PO daily (for heart failure rate control)
- Furosemide 40mg PO daily (for fluid management)
- Spironolactone 25mg PO daily (for heart failure)
- Atorvastatin 40mg PO daily (for hyperlipidaemia)
- Metformin 500mg PO BID (for Type 2 Diabetes)
- New Medications: None recently started or adjusted.
- Discontinued Medications: None recently stopped.
- Allergies: Penicillin (rash and itching).
Social History:
Patient lives alone in a ground floor flat. Daughter lives nearby and provides regular support. Smokes 5 cigarettes per day (attempted cessation multiple times in the past). Consumes alcohol socially, 1-2 units per week. Denies illicit drug use. Diet is generally balanced, but admits to occasional high-sodium meals. Light physical activity, walks short distances daily.
Family History:
Father passed away at 65 from a myocardial infarction. Mother has hypertension and Type 2 Diabetes. No history of sudden cardiac death or genetic conditions.
Review of Systems:
Constitutional: Increased fatigue. Denies fever, chills, night sweats. Cardiovascular: As per HPI. Respiratory: As per HPI, denies cough, wheeze. Gastrointestinal: Denies nausea, vomiting, diarrhoea, constipation. Genitourinary: Denies dysuria, frequency, urgency. Musculoskeletal: Denies joint pain, muscle weakness. Neurological: Denies headaches, numbness, tingling. Psychological: Denies depression, anxiety.
Physical Examination:
- Vital Signs: BP 118/72 mmHg, HR 78 bpm, RR 16 breaths/min, Temp 36.8°C, Weight 78.5 kg (+1.5kg from last visit), O2 Sat 96% on room air.
- General Appearance: Appears comfortable, no acute distress. Well-nourished, no cachexia or anasarca.
- Cardiovascular: S1, S2 audible. No S3, S4 noted. No murmurs or rubs. Peripheral pulses 2+ and symmetrical. JVD visible at 5 cm above sternal angle. No hepatojugular reflux.
- Pulmonary: Clear to auscultation bilaterally, no rales, rhonchi, or wheezes. Good air entry. No signs of pleural effusions.
- Abdominal: Soft, non-tender, non-distended. No ascites, hepatomegaly, or splenomegaly.
- Extremities: Bilateral +1 pitting oedema to ankles, easily compressible. Skin intact, no signs of poor perfusion.
Investigations/Labs:
- Recent Labs (1 November 2024): Na 138 mmol/L, K 4.2 mmol/L, Creatinine 110 µmol/L (eGFR 48 mL/min/1.73m2, stable), BNP 750 pg/mL (increased from 600 pg/mL last month). ECG (15 Oct 2024): Sinus rhythm, LBBB, consistent with prior. Echocardiogram (15 July 2024): LVEF 30%, mild mitral regurgitation.
Assessment:
Patient with chronic HFrEF, NYHA class II, presenting with signs and symptoms of mild fluid overload (increased fatigue, 1.5kg weight gain, +1 ankle oedema, increased BNP). Likely due to dietary indiscretion or sub-optimal diuretic dosing given recent weight gain and stable renal function. Patient remains stable overall with stable BP and no acute decompensation requiring hospitalisation.
Plan:
Management adjusted to address fluid retention and optimise symptom control.
- Medication Management: Increase Furosemide to 80mg PO daily for 3 days, then revert to 40mg daily if weight returns to baseline and oedema resolves. Review need for further long-term diuretic adjustment at next visit. Patient educated on importance of adherence and signs of dehydration.
- Fluid and Diet Management: Reinforce strict fluid restriction of 1.5L/day and low-sodium diet (<2g/day). Provided patient with updated dietary guidelines.
- Activity and Exercise: Encourage continued light walking. Advise against strenuous activities until symptoms improve. Discussed benefits of cardiac rehabilitation and provided local programme details.
- Monitoring: Instructed patient to monitor daily weight and report any further weight gain >2kg in 2 days, or worsening SOB/oedema. Repeat BNP and electrolytes in 1 week.
- Patient Education: Discussed symptoms of worsening heart failure and when to seek urgent medical attention. Emphasised importance of daily weights, medication adherence, and dietary restrictions.
- Referrals: No new referrals indicated at this time. Will consider referral to smoking cessation clinic if patient expresses readiness.
- Follow-up: Re-schedule follow-up with Cardiac Nurse in 2 weeks (15 November 2024) to reassess fluid status and medication efficacy.
Cardiac Nurse Heart Failure Template:
Reason for Visit: [detailed description of the patient's primary complaints or reasons for seeking care, including the duration and onset of symptoms] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
History of Presenting Illness:
[chronological account of the patient's current heart failure symptoms, including symptom characteristics, aggravating/alleviating factors, associated symptoms, and impact on daily activities] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- Symptoms reviewed:
- Shortness of Breath (SOB): [description of dyspnea, orthopnea, paroxysmal nocturnal dyspnea (PND), and exertional limitations] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- Oedema: [location, pitting vs non-pitting, and severity of swelling] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- Fatigue: [description of energy levels and impact on activities] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- Dizziness on standing or at rest: [description of dizziness symptoms, timing, and any episodes of syncope] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- Chest Pain/Discomfort: [character, location, radiation, and duration of chest symptoms] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- Palpitations: [description of heart rhythm irregularities, frequency, and associated symptoms] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- Weight Changes: [recent weight gain or loss, and associated fluid retention] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- Other: [any other relevant symptoms reported by the patient] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Past Medical History:
[comprehensive list of all active and inactive medical conditions, including cardiovascular diseases, metabolic conditions, renal disease, and respiratory conditions] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- Cardiac History:
- Heart Failure Aetiology: [underlying cause of heart failure, such as ischemic, non-ischemic, valvular, etc.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- Ejection Fraction (EF): [most recent documented ejection fraction and date of measurement] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- Hospitalizations for HF: [dates and reasons for previous heart failure-related hospital admissions] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- Interventions (e.g., PCI, CABG, valve surgery, device implantation): [details of any past cardiac procedures, including dates and outcomes] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Medications:
[current prescription medications, over-the-counter drugs, herbal supplements, and vitamins, including dosage, frequency, and adherence] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- Medication Reconciliation:
- [list of all current medications, specifying drug name, dose, route, frequency, and indication] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- New Medications: [any medications recently started or adjusted] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- Discontinued Medications: [any medications recently stopped and the reason] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- Allergies: [any known drug allergies and description of reaction] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Social History:
[patient's living situation, support system, smoking status, alcohol consumption, illicit drug use, dietary habits, and physical activity level] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Family History:
[relevant family medical history, particularly cardiovascular diseases, sudden cardiac death, and genetic conditions] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Review of Systems:
[a systematic inquiry about symptoms related to various body systems not covered in HPI, including constitutional, cardiovascular, respiratory, gastrointestinal, genitourinary, musculoskeletal, neurological, and psychological] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Physical Examination:
[objective findings from the physical examination, including vital signs, general appearance, cardiovascular, pulmonary, abdominal, and extremity findings] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- Vital Signs: [blood pressure, heart rate, respiratory rate, temperature, weight, and oxygen saturation] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- General Appearance: [overall impression of the patient, including distress, cachexia, or anasarca] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- Cardiovascular: [heart sounds (S1, S2, S3, S4), murmurs, rubs, peripheral pulses, jugular venous distention (JVD), and presence of hepatojugular reflux] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- Pulmonary: [respiratory effort, lung sounds (rales, rhonchi, wheezes), and presence of pleural effusions] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- Abdominal: [presence of ascites, hepatomegaly, or splenomegaly] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- Extremities: [presence and degree of peripheral edema, skin changes, and signs of poor perfusion] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Investigations/Labs:
[results of recent relevant laboratory tests (e.g., natriuretic peptides, electrolytes, renal function, liver function, thyroid function, complete blood count), ECG findings, echocardiogram results, and other imaging studies] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Assessment:
[summary of the patient's current clinical status, problem list, and working diagnosis related to heart failure and comorbidities, including functional class if applicable] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Plan:
[detailed outline of the management strategy, including medication adjustments, lifestyle modifications, follow-up schedule, patient education, referrals to other specialists, and goals of care] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- Medication Management: [specific changes to heart failure medications, including titration, initiation, or discontinuation, with rationale] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- Fluid and Diet Management:[recommendations for fluid restriction, sodium restriction, and dietary modifications] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- Activity and Exercise: [guidance on appropriate physical activity levels and cardiac rehabilitation if indicated] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- Monitoring: [parameters to monitor at home (e.g., daily weights, symptoms) and schedule for follow-up laboratory tests] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- Patient Education: [topics discussed with the patient, including symptom recognition, medication adherence, warning signs, and self-management strategies] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- Referrals: [any planned referrals to cardiology, palliative care, or other relevant services] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- Follow-up: [next scheduled appointment with the cardiac nurse or other providers] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
