Question

Mrs. M is a 76-year-old Caucasian female who presented to the emergency department with extreme weakness, shortness of breath and increasing ankle edema which has progressively worsened over the last two weeks. Mrs. M has a history of myocardial infarction 8 years ago requiring stents. In addition, Mrs. M medical history is significant for HTN, DM Type II and Stage 4 Chronic Kidney Disease. Ms. M sees her primary care physician often for adjustments of her diuretics. She notes her last ECHO was done a year ago and was 48%. Upon initial evaluation in the ED the patient’s serum creatinine is 1.2, sodium 135 potassium 3.8, calcium 10.5, magnesium 2.3, hemoglobin 10.2 hematocrit 32% WBCs 6.5. On initial assessment Mrs. H’s vital signs were as follows BP 95/58, HR 78bpm, Resp 24/min, O2 Sat 95% on room air. An ECHO confirms an EF of 35%.

Questions

1. Discuss your understanding of the medical diagnosis of Heart Failure, considering all of the information provided in the case study, and the pathophysiology of acute decompensated heart failure.

2. Discuss some of the common causes of Heart Failure. What do you think were some possible contributing factors that led to Ms. M exacerbation of heart failure?

3. Anticipate discharge teaching needs for Ms. M. What medications would you anticipate Ms. M to go home with? Be sure to include measures to avoid future exacerbations.

Answer 1

Answer 1. Anemia causes heart to work more to pump the blood as there is very less hemoglobin to carry O2 to all body parts. This anemia is a complication of CKD which has led to HF.

Hematocrit is low in CKD patients which in turn led the heart to pump more leading to heart failure.

Ejection fraction 38% indicates Heart failure wherein heart is not able to pump the blood efficiently.

Hyponatremia @ 138 Sodium levels indicate that due to heart failure there is an increased activity of Arginine Vasopressin hormone which increases reabsorption os free water into the renal tubules leads to diluted plasma with decreased sodium concentrations.

Answer 2:

valvular diseases like mitral valve stenosis or regurgitation

existing kidney disease

High BP

all above will lead to HF

3:

Diuretics

Anti hypertensives

ACE inhibitors

ARBs

If channel blockers

Beta blockers

Aldosterone antagonists

Isosorbide

Anticoagulants

Multi vitamins

Other supplements tc

There is a risk of increased Blood pressure and they may lead to stroke too so acitrom ecosprin need to be given.

Follow up consultation with ECHO, ECG, PT INR ratio etc.