case presenation

heart failure

Chief complaints (CC)
Exertional dyspnea, Orthopnea
History of present illness (HPI)
81 years old female presented in Emergency room with Increased SOB, exertional dyspnea for 3 days, Orthopnea,Pedal edema
Past medical history (PMHx)
Paroxysmal A Fib
Chronic HF
Mild pulmonary HTN
Past surgery: Appendectomy, Right hip replacement, Partial hysterectomy
Current medications
ASA EC 81 mg daily
Toprol XL 100 mg daily
Cozaar 100 mg daily
Lasix 80 mg daily
Lipitor 20 mg daily
K-Dur 20 mEq daily
Fosamax, Inspira, Lexapro
Social history (SocHx)
Non smoker, bowel and dietary habits normal.Denied smoking / ETOH
Lives with husband Sedentary lifestyle
Family history (FHx)
No premature CAD
Physical examination (PE)
Vitals: BT 37 BP 98/70 R 30 P 66, regular SpO2 77% on RA
GA: AAOx3, tachypneic Talks in broken sentences
HEENT: Mildly pale, anicteric sclera Dry oral mucosa. No thyroid enlargement
RS: Decreased bs lung bases Scattered crackles
CVS: JVD + 7 cm, Regular S1 S2, no S3/S4 SEM LPSB 2/6
Abd: BS+, soft, non-tender
Ext: pedal edema 1+
Laboratory results (Lab)
CBC WBC 15.7 Hb/Hct 12.1/35.5 Plt 227
Chemistry Na 138 K 4 Cl 98 HCO3 26 BUN/Cr 32/1.6 Ca / Mg 9.2 / 1.9 LFT - NL except TB 1.7
CIP CK /CKMB 124/3.3 Trop I 2.2
ABG 7.47 I 34 I 107 I 24
Other investigations
Chest X-ray
Cardiomegaly and pulmonary edema
EKG SR with 1st deg AV block 78 bpm New non specific ST-T changes in inferior and lateral leads
Echocardiogram EF 30% Pseudonormal pattern of LV diastolic filling Multiple segmental abnormalities (akinetic apex; hypokinetic mid posterior, lateral, septum, anterior, inferior segments.)‏ Mild TR Mild pulm HTN Mildly dilated left atrium
Differential diagnosis
Cardiogenic pulmonary edema
Non-cardiogenic pulmonary edema
COPD exacerbation
Pulmonary embolism
Case summary and impression
Conclusion: diagnosis, Acute decompensation of chronic HF
Pulmary edema
Decompensated chronic HF: Vasodilator + diuretics Pulmonary Edema MO + Vasodilators + Diuretics + Inotropes Hypertensive HF Vasodilator + diuretics Cardiogenic Shock Fluid challenge (250 cc in 10 min) + inotropes + norepinephrine + IABP Right HF Avoid MV; Suspect PE / RV MI Fluid challenge + inotropes AHF and ACS Early reperfusion
Started on: Dobutamine drip Lasix IV Nitropaste 9/25
Follow up
Clinically improved. Plan to: Restart ARB Restart BB Cardiac cath
Long-Term Medications
If already on ACEI/ARB -> continue If not -> start before discharge. BB maybe interrupted / reduced if Unstable with low output Severe AHF Bradycardia, adv AV block, cardiogenic shock Initiate BB before discharge, after pt stabilized on ACEI / ARB.

in brief

Patient 65 years, Female 
Shortness of breath, dizziness

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