Assignment: Case Study of Heart Failure
Assignment: Case Study of Heart Failure
A sixty-year-old baker presents to your clinic, complaining of increasing shortness of breath and nonproductive cough over the last month. She feels like she can\’t do as much activity as she used to do without becoming tired. She even has to sleep upright in her recliner at night to be able to breathe comfortably. She denies any chest pain, nausea, or sweating. Her past medical history is significant for high blood pressure and coronary artery disease. She had a hysterectomy in her 40s for heavy vaginal bleeding. She is married and is retiring from the local bakery soon. She denies any tobacco, alcohol, or drug use. Her mother died of a stroke, and her father died from prostate cancer. She denies any recent upper respiratory illness, and she has had no other symptoms. On examination, she is in no acute distress. Her blood pressure is 160/100, and her pulse is 100. She is afebrile, and her respiratory rate is 16. With auscultation, she has distant air sounds and she has late inspiratory crackles in both lower lobes. On cardiac examination, the S1 and S2 are distant and an S3 is heard over the apex.
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What is the chief complaint?
Based on the subjective and objective information provided what are your 3 top differential diagnosis listing the presumptive final diagnosis first?
What treatment plan would you consider utilizing current evidence based practice guidelines?
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Case Study Overview
[elementor-template id="165244"]In the case scenario, a 60-year old female patient presents with complaints of increased shortness of breath (SOB) and a non-productive cough in the last month. She reports that fatigue limits her daily activities and also has SOB when in a recumbent position. She has a medical history of coronary artery disease and high blood pressure. On physical examination, she is in no acute distress, BP of 160/100, a pulse of 100, and the respiratory rate is 16. On auscultation, there are distant air sounds and crackles in the lower lobes on late inspiration. Cardiac examination reveals distant SI and S2 and S3 perceived over the apex.
Chief Complaint
The chief complaints are shortness of breath, non-productive cough, and limitation of activity.
Differential Diagnosis
Left-Sided Heart Failure: The typical symptoms of heart failure include breathlessness, orthopnea, paroxysmal nocturnal dyspnea, reduced exercise tolerance, fatigue, prolonged time to recover after exercise, and ankle swelling (Redfield, 2016). Less typical symptoms include nocturnal cough, wheezing, confusion, palpitations, syncope, and bendopnea (dyspnea on bending over). Physical findings in heart failure include third heart sound, lateral displaced apical impulse, hepato jugular reflex, and tachycardia, dullness on percussion at the lung bases, pulmonary crackles and elevated jugular venous pressure (Ziaeian & Fonarow, 2016).
Heart failure is the most likely diagnosis as per the patient’s symptoms of SOB, cough, fatigue, and limitation of activity and a history of coronary artery disease. Besides, positive physical findings of tachycardia, distant air sounds, and crackles in the lower lobes make heart failure the most probable diagnosis.
Hypertensive heart disease: It is caused by a chronic high BP and presents with symptoms of chest pain, chest tightness, SOB, persistent cough, fatigue, ankle swelling and loss of appetite (Dawber, Moore & Mann, 2015). On physical examination, there is an elevated BP, high pulse, distended jugular veins, decreased breath sounds, ankle edema but with a normal S. Hypertensive heart disease is a possible diagnosis as per the symptoms of SOB, cough, fatigue, history of hypertension and physical findings of distant air sounds, high BP and an elevated pulse.
Cardiogenic Pulmonary Edema (CPE): Patients with CPE present with extreme SOB on exertion that has a sudden onset. Other symptoms include cough, profuse diaphoresis, orthopnea, and paroxysmal nocturnal dyspnea (Dawber, Moore, & Mann, 2015). Physical findings in CPE include tachycardia, tachypnea, hypertension, and fine rales at lung bases, and S gallop on auscultation (Ziaeian & Fonarow, 2016). CPE is a probable diagnosis based on the patient’s history of hypertension, cough, SOB on exertion, orthopnea, as well as physical findings of tachycardia, high BP, and S3.
Treatment Plan
Diagnostic tests: Investigations will include chest x-ray, electrocardiogram, echocardiography, and Natriuretic peptides level to assist in diagnoses of heart failure and to rule out differential diagnoses (Redfield, 2016).
Medications: Pharmacotherapy will aim at lowering BP and reducing morbidity.
- Carvedilol 25 mg BD; to improve left ventricular ejection fraction.
- Furosemide 40 mg BD; to control fluid status.
- Enalapril 10 mg BD; for vasodilatation and neurohormonal modification.
Health education: I will encourage the patient to adhere to the drug regimen, report adverse effects, and avoid NSAIDs. Nutritional counseling will be offered, the patient will be advised to avoid high sodium foods, alcohol, and have a balanced diet rich in vegetables, whole grains, and fruits (Redfield, 2016). Lastly, I will advise her to avoid strenuous exercises and take rests when experiencing breathlessness.
Follow-up: A follow-up visit will be scheduled after two weeks to monitor BP and evaluate progress. The patient will be advised to seek emergency care if her symptoms worsen.
References
Dawber, T. R., Moore, F. E., & Mann, G. V. (2015). II. Coronary heart disease in the Framingham study. International journal of epidemiology, 44(6), 1767-1780.
Redfield, M. M. (2016). Heart failure with preserved ejection fraction. New England Journal of Medicine, 375(19), 1868-1877.
Ziaeian, B., & Fonarow, G. C. (2016). Epidemiology and etiology of heart failure. Nature Reviews Cardiology, 13(6), 368.
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