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CHF

  • Exacerbation of CHF
  • Order 1:
  • Elevate head of bed
  • Pulse oximetry, stat and continuous
  • Oxygen, inhalation
  • IV access, stat
  • Cardiac monitor  
  • 12 lead EKG, stat Results:
  • Physical examinationOrder 2:Furosemide (Lasix), IV, stat and continuous
    Chest- X ray PA and lateral views, stat 
  • CBC with differential, stat
  • BMP, stat
  • CK-MB, stat, and every 8 hours x 2
    Troponin I, stat and every 8 hours x 2Results:Order 3:
  • Admit to ward
    Telemetry
    Ambulate at will
    Low salt diet
  • Low cholesterol diet
  • Diabetic diet
    Fluid restriction
  • Urine output
    Daily weights (type - weight, every day)
  • DVT prophylaxis (type - Pneumatic compression stockings)  
  • Continue all his home medications 
  • EKG, repeat in the morning
    BMP, next day (to check K and other electrolyte abnormalities with Lasix)
  • HbA1C, routine
  • Lipid profile, routine
  • Accucheck, every 6 hours
    KCL, oral, continuous (as long as you give Lasix)
  • Digoxin, oral, continuous
  • Echocardiogram, routine (to assess the left ventricular function)
  • Make sure the patient is on following medications for heart failure:
  • Aspirin
  • Digoxin
  • Beta blocker (metoprolol)
  • ACE inhibitor (Enalapril or lisinopril)
  • Diuretic
  • Next day
  • Examine the patient
  • Consider converting IV to oral diuretics
  • Determine if the patient stable for discharge?
  • Assess the need for oxygen therapy. The goal saturation is 92 to 96%. Wean the oxygen if his pulse oxygen shows saturations of >92.
  • Order 4:
  • At the time of discharge consider the following:
  • Patient education
  • Cardiac rehabilitation program
  • Smoking cessation program
  • Alcohol cessation program
  • Regular exercise
    Medication compliance 
  • Seat belt use
  • *Follow up in 2 weeksHold Beta blockers if

Dr. Soryal, George