Heart Failure Soap Note
Assessment:
Heart Failure:
Mr. Jones with past medical history of MI, and be came to clinic today complaining of DOE that began 6 months ago. Currently he developed edema on his low extremities, and he gained 13 lbs recently. His LVEF is less than 20%. His SOB is worsening in last 4 days, which he has a difficulty to breathe after 30 feet of walking. According to the ACC/AHA guidelines, his hemodynamic subset is class II, which he has a warm and wet due to his sign and symptoms of edema, ascites, and hypertension. Also, he is currently NYHA FC IV, as he can’t breathe regularly at when he lays down1. Currently he is not respond to thiazide (HCTZ). Thus an initial dose of diuretic (furosemide 40 mg qd) to attempt to get Mr. Jones to alleviate his edema and dyspnea symptoms, which is class I of recommendation. He also needs to monitor is K+ between 4.0 to 5.0 meq/L and BUN less than 20. Realizing that his LVEF is less than 20%, and he currently is hypovolemic, which is not increased the dosage of Metoprolol. Once he is euvolemic, Metoprolol dosage will be considered to increase to improve his LVEF. In additional he needs to monitor his diet. Also, he needs to stop naproxen for his pain. Naproxen is an NSAID class, which is contributed to worsen to his heart failure and MI condition. The APAP or Tramadol is recommended to treat his pain as needed. Also, the high dose of ASA is not showing better beneficial for his HF and MI condition. However, it has an inference with Lisinopril, which reduce Lisinopril’s efficacy, and ASP is needed to recude to 81 mg qd. The DASH diet is recommended for his current status, and he needs to watch and keep his sodium diet less than 3 grams per day. He also needs to keep weighting himself. He needs controlled his hypertension carefully. Hypertension plays an important role to increase the risk of his heart failure. Cough is likely a side effect that developed from Lisinopril. He is intolerance to ACEi, and he is
Heart Failure:
Mr. Jones with past medical history of MI, and be came to clinic today complaining of DOE that began 6 months ago. Currently he developed edema on his low extremities, and he gained 13 lbs recently. His LVEF is less than 20%. His SOB is worsening in last 4 days, which he has a difficulty to breathe after 30 feet of walking. According to the ACC/AHA guidelines, his hemodynamic subset is class II, which he has a warm and wet due to his sign and symptoms of edema, ascites, and hypertension. Also, he is currently NYHA FC IV, as he can’t breathe regularly at when he lays down1. Currently he is not respond to thiazide (HCTZ). Thus an initial dose of diuretic (furosemide 40 mg qd) to attempt to get Mr. Jones to alleviate his edema and dyspnea symptoms, which is class I of recommendation. He also needs to monitor is K+ between 4.0 to 5.0 meq/L and BUN less than 20. Realizing that his LVEF is less than 20%, and he currently is hypovolemic, which is not increased the dosage of Metoprolol. Once he is euvolemic, Metoprolol dosage will be considered to increase to improve his LVEF. In additional he needs to monitor his diet. Also, he needs to stop naproxen for his pain. Naproxen is an NSAID class, which is contributed to worsen to his heart failure and MI condition. The APAP or Tramadol is recommended to treat his pain as needed. Also, the high dose of ASA is not showing better beneficial for his HF and MI condition. However, it has an inference with Lisinopril, which reduce Lisinopril’s efficacy, and ASP is needed to recude to 81 mg qd. The DASH diet is recommended for his current status, and he needs to watch and keep his sodium diet less than 3 grams per day. He also needs to keep weighting himself. He needs controlled his hypertension carefully. Hypertension plays an important role to increase the risk of his heart failure. Cough is likely a side effect that developed from Lisinopril. He is intolerance to ACEi, and he is