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Topics: Hypertension, Myocardial infarction, Cardiology Pages: 7 (1134 words) Published: September 1, 2014
Mount Carmel College of Nursing
Columbus, Ohio

Nursing 521: Advanced Pathophysiology

CASE STUDY#1: CONGESTIVE HEART FAILURE

Stephanie Barber

September 21, 2011

INITIAL HISTORY:
66 year-old white male
increasing shortness of breath over the last month
noticed feet and ankles swelling by end of the day
has occasional episodes of chest tightness
has been waking up in the middle of the night with acute shortness of breath feels tired most of the time

1. Based on this information, what are the differential diagnoses?

R/O Impaired gas exchange↑o2 demand; alveolar compromise
pt states sob; nocturnal dyspnea

R/O Activity Intolerancethe patients feels tired most of the time

R/O Fluid Overloadthe patient states feet/ankle swelling @the end of the day

R/O Inadequate tissue perfusiond/t ↓cardiac output; pt states chest
tightness

PAST MEDICAL/SURGICAL HISTORY:
History of transmural anterior wall MI 7 years ago
3-vessel coronary artery bypass graft surgery 7 years ago
15-year history of hypertension

SOCIAL HISTORY:
2-pack/day smoker for 40 years--quit after bypass surgery
no alcohol or recreational drugs
works as janitor at a local elementary school
married with 2 children

FAMILY HISTORY:
father had MI at age 50, and died at age 70 with an MI
mother had hypertension, diabetes, and died after a stroke at age 82 one brother, age 58, with hypertension who had a coronary stent placed at age 57

CURRENT MEDICATIONS:
* NTG 1/150, SL., PRN
* Metoprolol 50mg, PO, BID
* ASA, PO, 81 mg QD

2. How has this additional information helped you focus your differential diagnosis?

The patient is an aging (66) male and has a significant cardiac history that includes MI, CABG, HTN, and smoking. In addition to his history there is a strong family history (MI, HTN, DM, CVA) which increases his risk as well. His current medication regimen most likely is not therapeutic as it does not include an ace inhibitor or diuretic.

3. The other most likely medications this patient should be receiving would include:

He should be on a diuretic. He is retaining fluid as evidenced by fatigue, shortness of breath, paroxysmal nocturnal dyspnea & lower extremity edema. If the patient has adequate insurance, I would recommend an ace inhibitor as well.

PHYSICAL EXAMINATION:
BP = 110/60 (sitting); HR: 104 irreg.; RR: 28/minute, slightly labored; T: 98.6; Weight: 82.5 kg; Sa02 95%

HEENT, Skin, Neck:
Funduscopic exam normal
Skin is pale, cool and dry extremities
Neck supple, no bruits over carotids
No thromegaly, no adenopathy
(+) Jugular vein distention (JVD); increased 6cm above sternal angle at 45 degrees CVP = 11 mmHg.

Lungs:
Bibasilar crackles that do not clear with cough
Cardiac:
PMI displaced laterally
Normal S1 and S2
(+) S3 at apex
Holostolic murmur at apex, radiating to axilla
Abdomen, Extremities, Neurological
2+ pitting edema in feet and ankles extending to midcalf bilaterally 2+ radial pulses, 1+ dorsalis pedis, and 1+ posterior tibial pulses bilaterally, skin cool alert and orient, appears anxious
cranial nerves intact, sensory intact
deep tendon reflexes (DTR) 2+ and symmetrical; strength 4.5 bilaterally

4. What findings on the physical exam support the diagnosis of heart failure?

Tachycardia (104); irregular rhythmtachypnea (rr 28,sat 95) slt labor +S3 gallop, +murmur(shortness of breath) +JVD, CVP=11bibasilar crackles (do not
Lateral displacement of PMIclear w c/db)
Pale, cool skin +1 pedal pulsesanxious/weak/fatigue
+2 ↓ext edema

5. What studies would you initiate while preparing for your interventions?

EKG-evaluate &dx irregular rate &rhythm
ABG-monitor gas exchange &pt compensation
CXR-assess cardiomegaly; infiltrates/effusion
BNP-significant predictor of HF
CBC-r/o anemia; infection
CHEM7,CA,MG,PHOS-assess...
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