Create a SOAP note for a 62-year-old female presenting with shortness of breath (SOB), fatigue, and ankle edema, suspected heart failure, including relevant contributory history, differential diagnoses, diagnostic workup, treatment plan, and follow‑up.

SOAP Note for Heart Failure Presentation

Subjective

Chief Complaint: [PATIENT], a 62-year-old female, presents with shortness of breath, fatigue, and ankle swelling.

History of Present Illness:

• Duration and progression: Breathlessness occurring both at rest and with exertion, progressive fatigue limiting daily activities, and bilateral ankle edema worsening over recent weeks 1, 2
• Associated symptoms to elicit: Orthopnea (number of pillows needed), paroxysmal nocturnal dyspnea, bendopnea, sudden weight gain (>2-3 kg in one week), decreased exercise tolerance, and profound fatigue 3, 4
• Atypical symptoms: Nausea, loss of appetite, restlessness, confusion, palpitations, or irregular pulse—these correlate with advanced functional class and warrant immediate attention 4

Contributory History (Risk Factors):

• Hypertension (most common cause of heart failure) 5
• Coronary artery disease or prior myocardial infarction 5
• Diabetes mellitus 5
• Thyroid disease (hyperthyroidism can precipitate high-output failure; hypothyroidism can worsen existing failure) 6
• Valvular heart disease, cardiomyopathy, or cardiotoxic drug exposure 5

Objective

Vital Signs:

• Blood pressure: May be elevated (hypertensive heart disease) or low (<90 mmHg systolic suggests low cardiac output) 7
• Heart rate: Tachycardia common; atrial fibrillation may be present 6, 3
• Respiratory rate: Tachypnea indicates pulmonary congestion 8
• Oxygen saturation: May be reduced with pulmonary edema 9

Physical Examination Findings:

• Jugular venous pressure (JVP): Elevated JVP (>8 cm H₂O) is the most prominent sign of right heart failure and systemic congestion 7, 8
• Cardiac: Displaced apical impulse (cardiomegaly), S3 gallop (volume overload), cardiac murmurs (valvular disease) 8, 2
• Pulmonary: Bibasilar crackles/rales indicate pulmonary congestion in left heart failure; normal lung sounds suggest isolated right heart failure 7, 8
• Extremities: Pitting edema starting at ankles, progressing upward with severity 7, 2
• Abdomen: Hepatomegaly (tender liver edge), hepatojugular reflux positive, ascites in advanced cases 7, 3
• Skin: Cool extremities suggest peripheral vasoconstriction and low cardiac output 7

Diagnostic Workup:

Initial Screening (Mandatory):

• 12-lead ECG: A normal ECG has >90% negative predictive value for excluding left ventricular systolic dysfunction; look for left ventricular hypertrophy, Q waves (prior MI), atrial fibrillation, or right axis deviation 1, 8
• Natriuretic peptides (BNP or NT-proBNP): Low-normal levels make heart failure unlikely; elevated levels support the diagnosis 8, 2

Confirmatory Testing:

• Transthoracic echocardiography: Mandatory to document structural/functional cardiac abnormality—measure left ventricular ejection fraction (LVEF) to classify as HFrEF (≤40%), HFmrEF (41-49%), or HFpEF (≥50%); assess diastolic function, valvular abnormalities, right ventricular function 1, 8

Additional Laboratory Tests:

• Complete blood count: Rule out anemia (can worsen heart failure) 1
• Serum electrolytes, creatinine, glucose: Assess renal function and metabolic status 1
• Liver enzymes: Evaluate hepatic congestion 1
• Thyroid-stimulating hormone (TSH): Thyroid dysfunction is a reversible cause 6
• Troponin: If acute coronary syndrome suspected as precipitant 1

Imaging:

• Chest X-ray: Cardiomegaly (cardiothoracic ratio >0.5), pulmonary venous congestion, pleural effusions 1, 2

Assessment

Primary Diagnosis: Heart failure—requires all three elements: symptoms (breathlessness, fatigue, edema) + signs (elevated JVP, crackles, peripheral edema) + objective cardiac abnormality on echocardiography 1, 8

Differential Diagnoses to Rule Out:

• Chronic obstructive pulmonary disease (COPD): Pulmonary function tests distinguish respiratory from cardiac dyspnea 1
• Pulmonary embolism: D-dimer, CT pulmonary angiography if high clinical suspicion 9
• Anemia: Complete blood count 1
• Renal failure with volume overload: Serum creatinine, urinalysis 1
• Thyroid disease: TSH level 6
• Liver cirrhosis with ascites: Liver function tests, abdominal ultrasound 1
• Venous insufficiency (isolated peripheral edema without elevated JVP): Doppler ultrasound of lower extremities 7

Classification:

• By LVEF: HFrEF, HFmrEF, or HFpEF based on echocardiography 1, 8
• By NYHA functional class: Class I (no limitation) to Class IV (symptoms at rest) 8, 2

Plan

Acute Management (If Symptomatic/Decompensated):

• Diuretics (loop diuretics, e.g., furosemide): Immediate symptom relief by reducing pulmonary and systemic congestion 1, 9
• Oxygen therapy: If hypoxemic 9
• Vasodilators (e.g., nitroglycerin): If hypertensive with pulmonary edema 9

Chronic Disease-Modifying Therapy (For HFrEF with LVEF ≤40%): The following combination reduces mortality and morbidity 1, 8:

• ACE inhibitor or ARB: Start immediately unless contraindicated 8
• Beta-blocker: Initiate once stable (not during acute decompensation) 8
• Mineralocorticoid receptor antagonist (MRA, e.g., spironolactone or eplerenone): Add for persistent symptoms or LVEF ≤35% 1, 8
• SGLT2 inhibitor: Emerging evidence supports mortality benefit 1

Device Therapy:

• Cardiac resynchronization therapy (CRT): Consider if LVEF ≤35%, QRS ≥120 ms, and NYHA class II-IV despite optimal medical therapy 1
• Implantable cardioverter-defibrillator (ICD): For primary prevention if LVEF ≤35% and life expectancy >1 year 1

Etiology-Specific Treatment:

• Coronary revascularization: If ischemic cardiomyopathy with viable myocardium 1
• Valve surgery or transcatheter intervention: If significant valvular disease 1
• Thyroid replacement or antithyroid therapy: If thyroid dysfunction identified 6

Lifestyle and Monitoring:

• Sodium restriction (<2 g/day), fluid restriction (1.5-2 L/day if severe), daily weights (report >2 kg gain in 3 days) 3
• Smoking cessation, alcohol limitation, regular low-intensity exercise once stable 1

Follow-Up:

• Reassess within 1-2 weeks after initiation of therapy to evaluate symptom response, electrolytes, and renal function 1
• Repeat echocardiography in 3-6 months to assess response to therapy and guide device decisions 1
• Long-term follow-up every 3-6 months for stable patients; more frequent if NYHA class III-IV 1

Common Pitfalls to Avoid:

• Do not diagnose heart failure based solely on echocardiographic findings (e.g., reduced LVEF) without documented symptoms—this is asymptomatic left ventricular dysfunction, not clinical heart failure 8
• Do not assume peripheral edema alone confirms heart failure—elevated JVP must be present to distinguish cardiac from non-cardiac causes 7
• Do not expect symptom severity to correlate with LVEF—patients with preserved LVEF can be severely symptomatic, and those with reduced LVEF may be asymptomatic 8, 4
• Always identify and document the underlying etiology (ischemic, hypertensive, valvular, etc.) because etiology-specific therapies are essential 1, 8

{"question": "Create a SOAP note for a 62-year-old female presenting with shortness of breath, fatigue, and ankle edema, suspected heart failure, including relevant contributory history, differential diagnoses, diagnostic workup, treatment plan, and follow-up."}