Heart Failure Case New
Chief Complaint
“I’ve been more short of breath lately. I can’t seem to walk as far as I used to, and
either my feet are growing or my shoes are shrinking!”
HPI
Rosemary Quincy is a 68-year-old African-American woman who presents to her
family medicine physician for evaluation of her shortness of breath and increased
swelling in her lower extremities. She reports that her shortness of breath has been
gradually increasing over the past 4 days. She has noticed that her shortness of
breath is particularly worse when she is lying in bed at night, and she has to prop
her head up with three pillows in order to sleep. She also reports exertional
dyspnea that is usual for her, but especially worse over the past couple of days.
PMH
Hypertension × 20 years
CHD with history of MI in 2005 (PCI performed and bare metal stents placed in LAD
and RCA)
Heart failure (NYHA FC III)
Type 2 DM × 25 years
Atrial fibrillation
COPD (GOLD 3, group D)
CKD (stage 4)
FH
Father died of lung cancer at age 71, mother died of MI at age 73.
SH
Reports occasional alcohol intake. States she has been trying to follow her low-
cholesterol and low-sodium diet. Former smoker (35 pack-year history; quit
approximately 10 years ago).
Meds
Valsartan 160 mg PO BID
Furosemide 40 mg PO BID
Warfarin 2.5 mg PO once daily
Carvedilol 3.125 mg PO BID
Pioglitazone 30 mg PO once daily
Glimepiride 2 mg PO once daily
Potassium chloride 20 mEq PO once daily
Atorvastatin 40 mg PO once daily
Aspirin 81 mg PO once daily
Albuterol MDI, two inhalations by mouth q 4–6 hours PRN shortness of breath
Tiotropium DPI 18 mcg, one inhalation by mouth daily
Fluticasone/salmeterol DPI 250 mcg/50 mcg, one inhalation by mouth BID
All
Lisinopril (cough)
ROS
Approximate 7-kg weight gain over the past week. No fever or chills. Denies any
recent chest pain, palpitations, or dizziness. Reports worsening shortness of breath
with exertion and three-pillow orthopnea. Describes a chronic, dry
(nonproductive), hacking cough, which she describes as usual without recent
worsening. No abdominal pain, nausea, constipation, or change in bowel habits.
Denies joint pain or weakness.
Physical Examination
Gen
African-American woman in moderate respiratory distress
VS
BP 134/76 (sitting; repeat 138/78), HR 65 (irreg irreg), RR 24, T 37°C, O2 sat 90% RA,
Ht 5′5″, Wt 79 kg (Wt 1 week ago: 72 kg)
Skin
Color pale and diaphoretic; no unusual lesions noted
HEENT
PERRLA; lips mildly cyanotic; dentures
Neck
(+) JVD at 30° (7 cm); no lymphadenopathy or thyromegaly
Lungs/Thorax
Crackles bilaterally, 2/3 of the way up; no expiratory wheezing
Heart
Irregularly irregular; (+) S3; displaced PMI
Abd
Soft, mildly tender, nondistended; (+) HJR; no masses, mild hepatosplenomegaly;
normal BS
Genit/Rect
Guaiac (–), genital examination not performed
MS/Ext
3+ pitting pedal edema bilaterally; radial and pedal pulses are of poor intensity
bilaterally
Neuro
A & O × 3, CNs intact. No motor deficits.
Labs
| Download (.pdf) | Print
Na 131 mEq/L Hgb 13 g/dL Mg 1.9 mEq/L INR 2.3
K 3.5 mEq/L Hct 40% Ca 9.3 mg/dL A1C 6.1%
Cl 99 mEq/L Plt 192 × 103/mm3 Phos 4.3 mg/dL
CO2 28 mEq/L WBC 9.1 × 103/mm3 AST 34 IU/L
BUN 32 mg/dL ALT 27 IU/L
SCr 2.3 mg/dL (baseline SCr 2.1 mg/dL)
eGFR 20 mL/minute/1.73 m2
Glucose 124 mg/dL
BNP 776 pg/mL (BNP drawn 2 months prior: 474 pg/mL)
ECG
Atrial fibrillation, LVH
Chest X-Ray
PA and lateral views (Fig. 18-1) show evidence of congestive failure with
cardiomegaly, interstitial edema, and some early alveolar edema. There is a small
right pleural effusion.
FIGURE 18-1.
A. PA CXR demonstrates increased vascular markings representative of interstitial
edema, with some early alveolar edema. The arrow points out fluid lying in the
fissure of the right lung. Note the presence of cardiomegaly. B. Lateral view of
CXR. Arrow points out the presence of pulmonary effusion.
View Full Size||Download Slide (.ppt)
View Full Size|
Favorite Figure
|Download Slide (.ppt)
No evidence of infiltrates; evidence of pulmonary edema suggestive of congestive
heart failure; enlarged cardiac silhouette.
Echocardiogram
LVH, reduced global left ventricular systolic function, estimated EF 20%; evidence
of impaired ventricular relaxation, stage 1 diastolic dysfunction
Assessment
Admit to hospital for acute exacerbation of heart failure
