Discussion Board
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A 66 year old male presents to your office complaining of shortness of breath for the past five days which has gotten progressively worse. His shortness of breath is worse when lying down and with exertion. He complains of a cough, especially at night. He also reports increased swelling in both legs bilaterally and mild substernal chest pressure. The patient has a history of diabetes, hypertension, and a prior myocardial infarction. His vital signs are: BP 208/102, HR 116, RR 28, T 98.4, 94% oxygen saturation. On exam you note rales in the lung bases bilaterally as well as 1+ pitting edema in the lower extremities bilaterally. The patient is sitting up and in no acute respiratory distress.
Provide the most likely diagnosis based on the HPI and PE. In addition, provide your interpretation of the cues found in the assessment.
List at least 3 possible differential diagnoses and justify your rationale. Develop therapeutic plan options based on quality, evidence-based clinical guidelines.
Based on HPI and PE, most likely diagnosis for this patient is Heart Failure. The patient has a history of diabetes, hypertension, and a prior myocardial infarction all of which contribute to structural modifications of heart and vascular system, causing decreased in heart muscle’s ability to eject appropriate amount of blood into peripheral system, where ejection fraction is reduced, indicating reduced strain as a result of poor ventricular systolic function. To confirm the diagnosis of heart failure, per American Heart Association and American Cardiology College, the provider would augment HPI and PE with EKG and labs, such as Natriuretic peptide biomarker screening; in addition, if further diagnostics are needed, an echocardiogram would be obtained at which point a heart failure diagnosis is confirmed (Fihn et al, 2014).
A perilous component of the HPI and PE is to evaluate for clinical congestion (i.e., those signs and symptoms resulting from elevated cardiac filling pressures). This patient is experiencing shortness of breath that’s getting worse, especially laying down and with activities, tachycardia, cough at night time, increased swelling in both legs bilaterally and mild substernal chest pressure. The patient is experiencing cardiac congestion: fluid buildup in lungs from decreased afterload causes shortness of breath, particularly when laying down and exerting activities, the dry cough is also associated with this pathology (Fihn et al, 2014). Due to lesser amount of blood reaching kidneys, the resulting water retention causes weight gain as well as ankle, leg and abdominal swelling. The cardiac muscle is triggered by stress receptor; therefore, the patent has tachycardia. This patient’s HPI and PE is indicative of Left-sided heart failure (Fihn et al, 2014).
Supportive measures include: life style changes must occur in order to prevent further deterioration. Initial behavioral and life style changes would recommend for smoking cessation, switching to DASH diet, increasing regular exercise, eliminating alcohol consumption, and reducing stress when possible. Pharmacologically, congestion is a target for medication adjustment and is associated with quality of life (QOL) and prognosis. The patient would be placed on ARBs to help to lower blood pressure and reduce cardiac work load and diuretic to help reduce risk of stroke, as indicated by AHA/ACC:
Losartan 50 mg PO, once daily initially; may increase to up to 100 mg/day
Hydrochlorothiazide 12.5 mg PO, once daily may be added in combination; may increase to up to 25 mg/day
In addition, initially the following lab evaluation will be completed to identify comorbidities, suitability for and adverse effects of treatments, potential causes or confounders of HF, severity and prognosis of heart failure (Fihn et al, 2014).
The differential diagnoses include:
Acute renal failure as evidenced by high BP, edema, worsening shortness of breath; however, ruled out due to no ascites and no skin discoloration, and only the lower extremity edema (ADA, 2022).
Acute respiratory distress syndrome (ARDS) as evidenced by worsening shortness of breath, crackles, and tachycardia; however, ruled out due to patient sitting in no apparent respiratory distress and oxygen saturation within normal limits (Fihn et al, 2014).
