CONGESTIVE HEART FAILURE

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CONGESTIVE HEART FAILURE

PATIENT CASE

History of Present Illness

H.J. presented to the ER late one evening complaining of a "racing heartbeat." She is an over-weight, 69-year-old white female, who has been experiencing increasing shortness of breath during the past two months and marked swelling of the ankles and feet during the past three weeks. She feels very weak and tired most of the time and has recently been waking up in the middle of the night with severe breathing problems. She has been sleeping with several pillows to keep herself propped up. Five years ago, she suffered a transmural (i.e., through the entire thickness of the ventricular wall), anterior wall (i.e., left ventricle) myocardial infarction. She received two-vessel coronary artery bypass surgery 4 ½ years ago for obstructions in the left anterior descending and left circumflex coronary arteries. Her family history is positive for atherosclerosis as her father died from a heart attack and her mother had several CVAs. She had been a three pack per day smoker for 30 years but quit smoking after her heart attack. She uses alcohol infrequently. She has a nine-year history of hypercholesterolemia. She is allergic to nuts, shellfish, strawberries, and hydralazine. Her medical history also includes diagnoses of osteoarthritis and gout. The patient is admitted to the hospital for a thorough examination.

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CONGESTIVE HEART FAILURE

Physical Examination and Laboratory Tests

Vital Signs

BP = 125/80 (left arm, sitting); P = 125 and regular; RR = 28 and labored; T = 98.5°F oral; Weight = 215 lb; Height= 5’8"; patient is appropriately anxious

Medications

Allopurinol bid after meal (treat gout)

Atorvastatin Q day (statin, decreases cholesterol)

Aspirin 325 mg QD

Clopidogrel Q day (antiplatelet)

Ibuprofen (NSAID, safe or not?)

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CONGESTIVE HEART FAILURE

Head, Eyes, Ears, Nose, and Throat

Funduscopic examination normal

Pharynx and nares clear

Tympanic membranes intact

Skin

Pale with cool extremities

Slightly diaphoretic

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CONGESTIVE HEART FAILURE

Neck

Neck supple with no bruits over carotid arteries

No thyromegaly or adenopathy

Positive JVD (jugular venous distension)

Positive HJR (hepatojugular reflex)

Lungs

Bibasilar rales with auscultation

Percussion was resonant throughout

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CONGESTIVE HEART FAILURE

Heart

PMI displaced laterally (point of maximal impulse)

Normal SI and S2 with distinct S3 at apex

No friction rubs or murmurs

Abdomen

Soft to palpation with no bruits or masses

Significant hepatomegaly and tenderness observed with deep palpation

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CONGESTIVE HEART FAILURE

Extremities

2+ pitting edema in feet and ankles extending bilaterally to mid-calf region

Cool, sweaty skin

Radial, dorsal pedis and posterior tibial pulses present and moderate in intensity

Neurological

Alert and oriented X 3 (to place, person, and time)

Cranial and sensory nerves intact

DTRs 2 + and symmetric (deep tendon reflex)

Strength is 3/5 throughout

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CONGESTIVE HEART FAILURE

Chest X-Ray

Prominent cardiomegaly

Perihilar shadows consistent with pulmonary edema (Bat-wing shape on frontal x-ay)

ECG

Sinus tachycardia with waveform abnormalities consistent with LVH

Pronounced Q waves consistent with previous myocardial infarction

ECHO

Cardiomegaly with poor left ventricular wall movement

Radionuclide Imaging

EF (ejection fraction) = 39%

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CONGESTIVE HEART FAILURE

Laboratory Blood Test Results

See Patient Case Table 3.1

Patient Case Table 3.1 Laboratory Blood Test Results

Na⁺                                             153 meq/L PaCO₂                                          53 torr

K⁺                                                3.2 meq/L PaO₂                                             65 torr (room air)

BUN                                             50 mg/dL WBC                                              5,100/mm³

Cr                                                 2.3 mg/dL Hct                                                 41%

Glu, fasting                                  131 mg/dL Hb                                                 13.7 g/dL

Ca⁺²                                            9.3 mg/dL Plt                                                  220,000/mm3

Mg⁺²                                           1.9 mg/dL Alb                                                 3.5 g/dL

Alk phos                                       81 IU/L TSH                                               1.9 μU/mL

AST                                              45 IU/L T₄                                                   9.1 μg/dL

pH                                                 7.35

Note. 1 torr = 0.999999857533699 mmHg. Can see torr or mmHg used.

Patient Case Table 3.1 Laboratory Blood Test Results
Na⁺ 153 meq/L	PaCO₂ 53 torr
K⁺ 3.2 meq/L	PaO₂ 65 torr (room air)
BUN 50 mg/dL	WBC 5,100/mm³
Cr 2.3 mg/dL	Hct 41%
Glu, fasting 131 mg/dL	Hb 13.7 g/dL
Ca⁺² 9.3 mg/dL	Plt 220,000/mm3
Mg⁺² 1.9 mg/dL	Alb 3.5 g/dL
Alk phos 81 IU/L	TSH 1.9 μU/mL
AST 45 IU/L	T₄ 9.1 μg/dL
pH 7.35

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CONGESTIVE HEART FAILURE

Clinical Course

After administration of the diuretic Lasix (furosemide), the patient voided 5,500 mL clear, yellow urine during the first 24 hours and another 4,500 mL during the second day post-admission. Bibasilar "crackles" subsided. Dependent edema was subsiding. The patient lost 10 pounds in total body weight. Vital signs were as follows: BP= 115/80 (right arm, sitting); P = 88 and regular; RR= 16 and unlabored; PaO₂ (room air) = 90; PaCO₂ = 44. H.J. was discharged on day 4 with prescription medicines and orders to pursue a follow-up with a cardiologist as soon as possible.

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CONGESTIVE HEART FAILURE

Clinical Values for Case Study Problem-Solving

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Clinical Values for Case Study Problem-Solving

Abbreviations

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Abbreviations