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)
Hypertension
Hyperlipidemia
Paroxysmal A Fib
Chronic HF
COPD
Mild pulmonary HTN
Past surgery: Appendectomy, Right hip replacement, Partial hysterectomy
Allergies
Sulfa
Current medications
Amiodarone
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
Pneumonia
Pulmonary embolism
MI
Case summary and impression
Conclusion: diagnosis, Acute decompensation of chronic HF
Pulmary edema
NSTEMI
Treatment
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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