BA is a 63 year old Caucasian female
ChiefComplaint:“Over the last 2 weeks. I often wake up in the middle of the nightshort of breath. I cough frequently and the feeling of tiredness hasbecome common. I find it hard to walk for a couple of meters withoutfeeling very exhausted. I have noticed that my legs are steadilyswelling and over the last one month, I have gained more than 10pounds.
SUBJECTIVEHISTORY: BA complains of fatigue and dyspnea that has been ongoingfor over a month. She was recently diagnosed with Osteoarthritis (OA)which led to her giving up her daily exercising. The frequent feelingof extreme exhaustion also contributed to her giving up her routineexercises. She coughs frequently, but without sputum and finds ithard to go on with her ADL. BLE edema noted over the past few weeks.Denies any incidence of chest pain and self-reported a weight gain of10-12 pounds in the last one month.
Pastmedical History: Diagnosedwith CAD and HTN aged 52 Diagnosed with T2DM when aged 58 OAdiagnosed recently at the age of 61
ImmunizationPneumococcal and influenza vaccine. No history of surgery
FamilyHistory: Fatherdeceased at the age of 67 S/P MI. Mother HTN. One sister who is in ahealthy condition.
SocialHistory: BAis a retired hotel attendant. Lives with husband, a retired mechanic,and together they have 4 grown up children and 2 grandchildren. Pasthistory of tobacco and alcohol use. Quit tobacco use more than 10years ago had a history of 40-packs a year.
Medication:Sotalol120 mg PO BID. HCTZ 20mg PO daily, Celecoxib 195mg BID andSimvastatin 40mg PO just before bedtime.
OBJECTIVE(Physical examination and diagnostic) General- Obese Caucasianfemale. Well developed and with noticeable SOB.
Vitalsigns- HR 55, BP 110/78, RR 20, Wt 70kg, T 98.5 F, Ht 5’3”
HEENT-Denies headache, EOMI, PERRL, denies any changes in vision andhearing. Denies sore throat and dizziness
Neck-No bruits, + JVD to 11cm
Chest-Crackles in bilateral lower lobes, decreased breathing. Denies painwith expiration and inhalation
Abdomen-ND, soft, positive bowel sounds, positive hepatojugular reflex
Neuro-A & O X 4
Ext-Cool to touch, 2 + edema to knees
Laband diagnostic testsNa 134, Cl 100, Alb 43, K 4.3, C02 26, bun 11.4, Glucose 8.1, AST 1(60), Alc 7.6%, BNP 126g pg/Ml, Hct 0.34 (34), T Bili 15.4 (0.4)
FastingCholestrol- 4.63 mmol/L (180mg/Dl), LDL 2.1 mmol/L (90 mg/dL), HDL1.53 mmol/L (60mg/dl)
ECG:Ventricular rate 53, Sinus brady Cardia
ECHOLV end systolic dimension-5.0cm, LV end diastolic dimension-6.1cm, LAdimension-4.0 cm, anterior hypokinesis, inferior hypokinesis,ejection fraction-37%, mild mitral regurgitation.
ASSESSMENT:According to the physical examination, lab test as well asobserved symptoms, diagnosis of Bradycardia, new onset of heartfailure, chronic kidney disease as well as ACE inhibition allergy wassuggested. The listed diagnostics and lab tests would be analyzed inorder to rule out Acute Coronary syndrome. The patient will have tobe transferred to the emergency department if possible out AcuteCoronary syndrome is indicated by the lab test or ekg . Butler(2012) points out that the onset heart failure is characterized bysymptoms such as breathlessness, swelling of the ankles as well asfrequent incidences of fatigue. Other typical signs are raisedjugular venous pressure (JVP), tachycardia, pleural effusion,hepatomegaly and peripheral oedema. Butler adds that physicalsymptoms such as cardiac murmurs, third heart sound as well as raisednatriuretic peptide concentration may indicate a new onset of heartfailure. Heart failure can be categorized into acute heart failureand chronic heart failure. A new onset is described as acute heartfailure. As the condition gets worse, more fluids would build up inthe patient’s body and the patient will start feeling boated and afrequent need to urinate, especially at night.
Theestimated creatinine clearance points to a stage 4 chronic kidneydisease. Symptoms include reduced GFR rate to around 15-30 ml perminute and uremia. Fatigue, urination change and sleep problems aresome of the symptoms of state 4 kidney disease. Over the weeks andmonths, the condition gets worse until the kidney losses itsfunctionality and is no longer able to remove the excess fluids fromthe body. The abnormal heart sounds point to the fact the patient maybe in the early stages of CKD (W.I.C, 2010). Another problem isBradycardia characterized by the low rate at which the heart pumpsblood. Among adults, it is described as a heart rate below 60 beatsper minute. This combined with the frequent episodes of fatigue aresecondary to sotatol accumulation as well as CKD. Causes ofBradycardia include heart medication, past family history of thedisease, heart block as well as sick sinus syndrome.
Differentialdiagnosis A number of disorders can result to impaired cardiacfunction. To differentiate noncardionegic from cardionegic pulmonaryedema, hemorrhagic shocks as well as increased levels of capillarypermeability are observed in noncardiogenic pulmonary edema. This isalso the case with ARDS and administration of certain drugs (Hosenpud& Greenberg, 2009). Progressive symptoms of heart failure aswell as past history of an acute cardiac problem point to earlystages of congestive heart failure. Elevated jugular venous pulsationand s3 gallop will be more effective in pointing out acute congestiveheart failure. Measurement of pulmonary capillary wedge pressure(PCWP) of more than 18 mm Hg will also provide a strong evidence ofcongestive heart failure. Nausea, abdominal pain especially on theright side as well as vomiting is some of the observable syndromesassociated with heart failure. Confusion and fatigue is common amongelderly persons (Hosenpud & Greenberg, 2009)
PLAN:Sharma & Callans (2013) point out that heart failure affectsabout 5 million patients in the US and that more than 500,000 arediagnose with acute heart failure each other year. They suggest anumber of therapeutic considerations such as rhythm control,ventricular rate control as well as the ablation and pacemakertherapy. Patient BA would be admitted to the hospital for thecommencement of the work-up for the new onset of heart failure. Oxygen saturation will be titrated to less the 92 % and 20mg of IV furosemide administered in a single dose. The patient willalso have his cardiac enzymes boosted 3 times more. A secondary doseof IV furosemide would be administered if the patient does notrespond to the initial dose. Eltrolytes would be monitored forhypomagemesimia and hypokalemia. Angiodema will be discussed withpatient after which angiotensin receptor blocker would be initiated.Strict I/O’s as well as daily weights would be recommended.
ForBradycardia, the use of Sotatol would be discontinued. This wouldtaper the beta-blocker thus leading to normal elimination of renalfluids. The patients vital signs will have to be monitored every 3-4hours. Magnesium levels would be assessed and its use replaced ifhypomagnesimic sets in. For CKD, I/O’s, BUN/SCr and electrolyteswould be monitored. The current levels of BA’s kidney functionwould be assessed to find out whether the current function is AB’sbaseline kidney function. Secondary complications of CKD would beworked out and a nephrologist consulted based on the guidelines forthe management of stage 3-4 of CKD. The use of HTCZ would bediscontinued and furosemide 40 mg use initiated on a daily basis. HRand BP would be monitored every 4 hours.
Butler,J. (2012). Primary prevention of heart failure. ISRNCardiology,2012.
Hosenpud,J., & Greenberg, B. (2009). Congestiveheart failure(2nd ed.). Philadelphia: Lippincott Williams & Wilkins.
Sharma,P., & Callans, D. (2013). Treatment Considerations for a DualEpidemic of Atrial Fibrillation and Heart FailureTreatmentConsiderations for a Dual Epidemic of Atrial Fibrillation and HeartFailure. JAFIB:Journal Of Atrial Fibrillation,6(2).
W.I.C.(2010). Chronic Kidney disease.