Question

Patient History

Mr. N is 54 years old and slightly obese. He has no known drug or food allergies. He denies use of illegal drugs and states that he occasionally has “a glass of wine with dinner at a restaurant.” He has no family history of diabetes. In the past year, Mr. N was prescribed ASA 81 mg and Colace orally daily. He also was diagnosed with hypertension approximately 7 months ago and is currently taking Hyzaar 100/25 orally at bedtime. Approximately 3 months ago, he also began taking Toprol-XL 50 mg orally every morning. Denies the use of herbal treatments. Surgeries include cataract removal from the left eye 8 months ago, an appendectomy at the age of 20 years old, and T & A at age 7 years. Mr. N is married and has 4 living children. One child died at age 8 months of SIDS. His father died at age 80 of congestive heart failure, and his mother at age 75 of ovarian cancer.

Clinical Assessment

Mr. N presents with complaint of episodes of tachycardia, tachypnea, and states, “my blood pressure keeps going up every time I check it.” He has felt fatigued for a few weeks and has had frequent nocturnal urination for the past 4 months. He says that he just does not “feel good.” Current vital signs include: temperature 99.0˚F, pulse 122 and weak, respirations 24 and labored, BP 146/100. Skin dry but cool to the touch. Crackles noted on auscultation. Perioral cyanosis, but slight cyanosis of nail beds. Capillary refill 4 seconds. O₂ saturation 90% with oxygen in progress via nasal cannula at 6 L/min. ECG shows sinus tachycardia. He states that he can breathe better when head of bed is elevated approximately 45 degrees. Lab values are pending.

Diagnosis

Left ventricular failure

Hypertension

Prognosis

Good with compliance with treatment regimen

Questions

1. What are some factors that point to the current diagnosis of left ventricular failure, although the lab values have not yet been received?

2. Does left ventricular failure always present with such specific signs/symptoms as those noted for Mr. N? Explain your answer.

3. Because Mr. N presents with signs/symptoms of left ventricular failure, should there be any concern related to the condition of the right side of the heart? If no concern, why not? If there is concern, why?

4. What should be included in the instructions for the patient and his family at the time of his discharge? The patient and family will need detailed instructions that would minimally include:

Answer 1

1. Factors that support the diagnosis of Left ventricular failure in the patient is

- Crackles noted on auscultation

- Perioral cyanosis, but slight cyanosis of nail beds and capillary refill 4 seconds.

- O₂ saturation 90% with oxygen

- Sinus tachycardia

2. Yes, left ventricular failure always present with such specific signs/symptoms as those noted for Mr. N because

- Crackles noted on auscultation (It is a sign of pulmonary edema which is normally occurred due to heart failure because of fluid overload in lungs, pulmonary edema is also supported by patients statement "He states that he can breathe better when the head of the bed is elevated approximately 45 degrees" )

- Perioral cyanosis, but slight cyanosis of nail beds and capillary refill 4 seconds indicated poor blood supply due to left ventricular failure. bEcause in left ventricular failure heart does not pump efficiently and does not pump adequate blood.

- Tachycardia (Tachycardia is common in left ventricular failure because heart try to maintain blood pressure by pumping harder)

3.

Mr. N presents with signs/symptoms of left ventricular failure but there is a concern related to the condition of the right side of the heart because due to failure of left ventricle there is fluid overload occurs in lungs which builds the pressure over right ventricle, it eventually leads to right-sided heart failure.

4.

instructions for the patient and his family at the time of his discharge should incudes

- You should not do heavy work as you heart not able to handle it.

- Regular minimal exercise is good for the heart

- Eat saturated fat and trans-fat free diet.

- Reduce carbohydrate intake.

- Check blood pressure regularly and don't skip any medication.

- If you feel any type of chest discomfort or difficulty in breathing then visit hospital imediatly.

- Visit for follow up regularly.

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