Mrs. Johnson is a 65-year-old female who presents to the ED with complaints of shortness of breath, fatigue, bilateral leg swelling, and a recent weight gain of 10 pounds in the last three days. She reports difficulty sleeping over the last week and states “whenever I lay down, I feel like I can’t breathe”. She also reports using multiple pillows to prop herself up and “that’s the only way I can sleep”. Mrs. Johnson has a recent history of myocardial infarction (MI) 2 weeks prior to this visit. The patient has an additional history of high blood pressure, high cholesterol, and diabetes. She is 5 feet tall and weighs 205 pounds. Prior to the diagnosis of the MI, the patient was noncompliant with all medications and lived a sedentary lifestyle. After the MI, the patient was discharged on a medication regimen and states has been compliant thus far.
PHYSICAL EXAMINATION:
Vital signs on arrival to ED: blood pressure 187/104, heart rate 115, respirations 24 and labored, temperature 98.2 degrees Fahrenheit, and oxygen saturation 85% on room air.
Auscultation reveals crackles and rales at the bases of both lungs. Bilateral pitting edema to bilateral lower extremities and the presence of an S3 heart sound.
LAB WORK:
CBC – H/H 12.4/43, WBC 18,000/mm3; neutrophils 70%, bands 12%, lymphocytes 12%.
BMP – unremarkable
BNP- 989
UA – unremarkable
PA and Lateral chest x-ray reveal bilateral pleural effusions and cardiomegaly.
EKG showed Sinus Tachycardia with no new changes.
Echo showed left ventricular hypertrophy and an ejection fraction of 25%
Answer the following questions:
1. Identify contributing problems from the patient’s history.
2. Explain the significance of the physical findings.
3. Review the labwork and diagnostic testing. How do the results support the CHF diagnosis?
4. What is the difference between left sided and right sided heart failure?
5. What type of heart failure is Mrs. Blake likely to have and why?
6. Mrs. Blake is prescribed and ACE inhibitor (enalapril), beta blocker (cardvedilol) and diuretic (furosemide) as part of his medication regiment that will continue when discharged. What patient education should be provided regarding these medications?
7. With no previous history of CHF, is this an acute or chronic condition at this time?
8. Explain the pathophysiology of acute heart failure and the main reason for its’ development in this patient.
9. Is there an ethnic or genetic predisposition for developing CHF?
10. What kind of discharge education would this patient require to reduce the chance of readmission for CHF exacerbation?
