Patient Information:
Age: 75 years
Gender: Female
Subjective Data:
CC (chief complaint): Leg swellig and shortness of breath
HPI: A 75-year-old female patient presented to the emergency department with complaints of shortness of breath for three days. The shortness of breath is progressive and initially occurred with exertion but is currently experienced even at rest. The shortness of breath is partially relieved by sitting in a propped-up position and is exacerbated by lying flat and physical activity. The patient also complains of a dry nocturnal cough with no associated chest pain or hotness of the body. There is associated awareness of heartbeat and easy fatigability. There is also repo bilateral lower limb swelling that was gradual in onset and has been progressive over the last month. The patient denies any paroxysmal nocturnal dyspnea.
Current Medications: The patient is on metformin 500 mg once daily and glipizide 2.5 mg once per day. She is on a low salt restriction diet for high blood pressure that she rarely follows.
Allergies: She denies the presence of any allergies to any medication, food, or environmental elements.
PMH: The patient is a known diabetic on care. She also has hypertension and is being managed conservatively on a low-salt
diet.
Surgical History: The patient underwent a myomectomy for fibroids in the past.
Social History: The patient is a retired nurse. She is married with three children who are alive and healthy. She denies any history of smoking cigarettes or consuming alcohol.
Family History: There is a positive family history of diabetes, heart failure, and hypertension. Her deceased father had diabetes and her mother had heart failure.
ROS:
GENERAL: The patient denies recent unintentional weight loss or fever.
HEENT: The patient reports declining vision attributed to cataracts. She has no hearing loss, sore throat, or running nose.
RESPIRATORY: There is a dry nocturnal cough and exertional dyspnea. There is no wheeze or chest pain.
GASTROINTESTINAL: There is no nausea, vomiting, blood in stool, diarrhea, constipation, and abdominal pain.
GENITOURINARY: She denies any pain or discomfort upon urination, blood in urine, flank pain, morning facial puffiness, frequency, urinary incontinence, or foul-smelling urine.
NEUROLOGICAL: The patient reports no experience of headaches, dizziness, seizures, numbness, weakness, paralysis,
or slurred speech.
MUSCULOSKELETAL: There are no reported myalgias, joint pain, swelling, or stiffness.
HEMATOLOGIC: She denies anemia, bleeding tendency, and easy bruising.
LYMPHATICS: Patient denies lymph node of spleen enlargement.
PSYCHIATRIC: There are no hallucinations, delusions, mood disturbance, or history of any psychiatric condition.
ENDOCRINOLOGIC: The patient denies experiencing heat or cold intolerance, or excessive diaphoresis. She reports polydipsia, polyphagia, and polyuria.
SKIN: There is no reported pruritus or skin rash.
ALLERGIES: She reports no allergic reactions or atopic disorders.
Objective Data:
Physical exam:
VITALS: BP 155/85 mmHg, PR 102, RR 28, Temperature 98, SpO2 84% on room air, BMI 26.8
GENERAL: The patient is fully conscious, in respiratory distress, seated propped up, and speaks in incomplete sentences. She is otherwise well-kempt and well-hydrated.
HEENT: The head is normocephalic. Cataracts are present and the pupils are equally and bilaterally reactive to light. There is no scleral jaundice. She has good oral hygiene, no swollen tonsils, no nasal congestion, and minimal wax in the ear canals. Her neck veins are prominent and distended.
RESPIRATORY: On inspection, the chest rises with respiration, there are no scars or chest wall deformities. The chest expands symmetrically. There is dullness to percussion on the bases of the lungs. Auscultation reveals equal good air entry a. However, crackles were present on lung bases bilaterally.
CARDIOVASCULAR: There is elevation of the jugular venous pressure. The precordium is hyperactive. the apex beat was displaced inferiorly to the 6th intercostal space and lateral to the midclavicular line was noted. The first and second heart sounds are heard with an added third heart sound. There is a systolic murmur with radiation to the left axilla. There are no heaves or thrills.
ABDOMINAL: The abdomen is slightly distended and moves with respiration. There is mild tender hepatomegaly, no splenomegaly or any other mass elicited. The fluid thrill and shifting dullness are positive. Bowel sounds were present.
MUSCULOSKELETAL: There is bilateral non-tender pitting edema of the lower limbs up to the level of just below the knee. There is no joint stiffness or pain or limitation in the range of motion in all joints is normal.
NEUROLOGICAL: The patient is alert with a GCS of 15/15. There are normal findings on the assessment of all cranial nerves. Motor examination reveals normal bulk, tone, muscle power, and reflexes. The sensation is intact.
SKIN: The skin is cold and clammy. There are no rashes or other lesions seen.
Diagnostic results:
A complete blood count revealed normal findings of cell counts but low hemoglobin levels of 9.0 g/dL.
Random blood sugar showed a blood glucose level of 110mg/dL.
Liver function tests were within normal ranges.
The lipid profile was normal.
The coagulation profile was normal.
Blood urea, nitrogen, and electrolytes were within normal ranges.
A Chest X-ray showed cardiomegaly and features suggestive of pulmonary congestion of bilateral pleural effusions and prominent upper lung zone vasculature.
Assessment:
Differential Diagnoses
Congestive Heart Failure: This is the most probable primary diagnosis. The patient presented with typical signs and symptoms of congestive heart failure such as dyspnea, orthopnea, lower limb edema, palpitations, and easy fatigability (Joshi et al., 2020). The findings on examination such as elevated jugular venous pressure, pulmonary crackles, ascites, tender hepatic congestion, displaced apex beat, and a third heart sound are suggestive of congestive heart failure (Schwinger et al., 2021). Cardiomegaly and pulmonary congestion on chest X-ray further support this diagnosis. The predisposing risk factors present in this patient are advanced age, comorbid diabetes, a family history of heart disease by her mother, and hypertension of which she is not compliant with the conservative clinical recommendation of dietary salt restriction (Schwinger et al., 2021). The progressive shortness of breath that is currently experienced even at rest may represent worsening disease severity or an exacerbation. This necessitates prompt and adequate treatment to prevent worsening prognosis and improve the quality of life and functional status of the patient.
Chronic kidney disease: This is the other likely diagnosis. Chronic kidney disease presents with lower limb edema, dyspnea, hypertension, and anemia all of which the patient presented with (Chen et al., 2019). However, other typical features such as morning facial puffiness, pruritus, and encephalopathy were absent. Preexisting diabetes and hypertension may be the possible predisposing factors to renal disease. Serum urea, nitrogen, and electrolytes were within normal ranges thus dispelling the possibility of this diagnosis. The presence of tender hepatomegaly, orthopnea, and cardiomegaly make congestive heart failure a more likely diagnosis than chronic kidney disease. Further investigations may be needed to rule out this diagnosis such as determining the glomerular filtration rate and obtaining a renal ultrasound.
Acute Respiratory Distress Syndrome: Acute Respiratory Distress Syndrome is a likely diagnosis since it presents with hypoxemia, dyspnea, tachypnea, and pulmonary edema (Matthay et al., 2019). These features were evident in this patient including a low oxygen saturation on pulse oximetry. The causes of acute respiratory distress syndrome such as pneumonia, sepsis, chest trauma, and aspiration were absent thus making this diagnosis unlikely (Matthay et ., 2019). The presence of lower limb edema, tender hepatomegaly, and ascites can not be explained by this diagnosis. The noted pulmonary congestion and edema secondary to heart failure can adequately justify the occurrence of dyspnea and tachypnea.
Plan
Additional Diagnostic Tests
Electrocardiogram and Echocardiogram to determine the ejection fraction, identify any structural abnormalities, and classify whether the heart failure is systolic or diastolic.
Abdominal ultrasound to rule out the presence of liver or kidney disease that may have presentations similar to those of the patient.
Non-Pharmacologic Interventions:
Fluid and salt restriction will be recommended to prevent exacerbation of the fluid overload.
Additional conservative measures will include lifestyle modifications that entail regular exercises and physical activity once the patient feels better, a healthy diet, and weight control.
Pharmacological Management:
Oxygen will be administered via a facemask since the patient is in respiratory distress with reduced oxygen saturation.
Fluid overload manifesting as bilateral lower limb edema, ascites, and pulmonary edema will necessitate the administration of diuretic agents such as furosemide 40 mg twice a day and spironolactone 20 mg once daily.
The presence of symptomatic heart failure will warrant the administration of an ACE inhibitor such as lisinopril 40 mg daily. The addition of a beta-blocker such as carvedilol 25 mg twice daily and cardiac glycoside such as digoxin 0.125 mg daily may be necessary depending on findings of structural abnormalities and reduced ejection fraction from the echocardiogram.
Geriatric Considerations
The choice of treatment interventions will depend on various factors. These include the cost of the drugs, patient preference, safety, and efficacy. Information regarding the available treatment options should be provided to the patient. This will enable them to make informed decisions without coercion. Since the patient falls within the geriatric population, considerations such as cognitive ability in comprehending clinical recommendations should not be ignored. The reduced capacity for self-care and self-efficacy in activities such as physical activity may necessitate assistance from caregivers. The patient’s religious beliefs may conflict with the plan of care. This will necessitate open communication on the need for therapeutic interventions and explore available alternatives. The healthcare professional will need to have religious competence to address the patient’s needs holistically.
Health Education
Adherence to treatment recommendations will be emphasized to improve the effectiveness of the plan of care and reduce readmission rates, and future exacerbations. These will include anti-diabetic and anti-failure medication and health-promoting behaviors. The patient will also be educated on the recognition of symptoms to enable prompt management of acute exacerbations.
Disposition
The patient will be admitted to the medical ward for further management. Upon discharge, the patient will be followed up through regular checkups to ensure continuity of care and evaluate treatment outcomes.
References
Chen, T. K., Knicely, D. H., & Grams, M. E. (2019). Chronic kidney disease diagnosis and management. JAMA, 322(13), 1294. https://doi.org/10.1001/jama.2019.14745
Joshi, R., Bansal, A., Padappayil, R. P., Gopal, S., & Garg, M. (2020). Practice patterns in the management of congestive heart failure and post-discharge quality of life: A hospital-based cross-sectional study. Journal of Family Medicine and Primary Care, 9(11), 5592. https://doi.org/10.4103/jfmpc.jfmpc_218_20
Matthay, M. A., Zemans, R. L., Zimmerman, G. A., Arabi, Y. M., Beitler, J. R., Mercat, A., Herridge, M., Randolph, A. G., & Calfee, C. S. (2019). Acute respiratory distress syndrome. Nature Reviews Disease Primers, 5(1). https://doi.org/10.1038/s41572-019-0069-0
Schwinger, R. H. (2021). Pathophysiology of heart failure. Cardiovascular Diagnosis and Therapy, 11(1), 263–276. https://doi.org/10.21037/cdt-20-302
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Important information for writing discussion questions and participation
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Hello class and welcome to the class and I will be your instructor for this course. This is a -week course and requires a lot of time commitment, organization, and a high level of dedication. Please use the class syllabus to guide you through all the assignments required for the course. I have also attached the classroom policies to this announcement to know your expectations for this course. Please review this document carefully and ask me any questions if you do. You could email me at any time or send me a message via the “message” icon in halo if you need to contact me. I check my email regularly, so you should get a response within 24 hours. If you have not heard from me within 24 hours and need to contact me urgently, please send a follow up text to
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I understand this is a lot of information to cover in 5 weeks, however, the Bible says in Philippians 4:13 that we can do all things through Christ that strengthens us. Even in times like this, we are encouraged by God’s word that we have that ability in us to succeed with His strength. I pray that each and every one of you receives strength for this course and life generally as we navigate through this pandemic that is shaking our world today. Relax and enjoy the course!
Hi Class,
Please read through the following information on writing a Discussion question response and participation posts.
Contact me if you have any questions.
Important information on Writing a Discussion Question
- Your response needs to be a minimum of 150 words (not including your list of references)
- There needs to be at least TWO references with ONE being a peer reviewed professional journal article.
- Include in-text citations in your response
- Do not include quotes—instead summarize and paraphrase the information
- Follow APA-7th edition
- Points will be deducted if the above is not followed
Participation –replies to your classmates or instructor
- A minimum of 6 responses per week, on at least 3 days of the week.
- Each response needs at least ONE reference with citations—best if it is a peer reviewed journal article
- Each response needs to be at least 75 words in length (does not include your list of references)
- Responses need to be substantive by bringing information to the discussion or further enhance the discussion. Responses of “I agree” or “great post” does not count for the word count.
- Follow APA 7th edition
- Points will be deducted if the above is not followed
- Remember to use and follow APA-7th edition for all weekly assignments, discussion questions, and participation points.
- Here are some helpful links
- Student paper example
- Citing Sources
- The Writing Center is a great resource