Case Study
Published on Nov 18, 2015
No Description
MORE DECKS TO EXPLORE
PRESENTATION OUTLINE
Maria is a 50 yr old woman who developed 5/10 substernal chest pain and SOB in the airport after flying into Denver from Florida. Paramedics responded and transported her to the hospital. She was A&O, VSS, and mild oxygen desaturation at 88%. EKG showed NSR with no acute abnormalities. HR 90. Hx includes HTN for 20 yrs., mild obesity, and hyperlipidemia. She has a 30 pack yr. hx. Of smoking and no hx. of illicit drug or alcohol abuse.
Her risk factors for coronary disease include HTN, hyperlipidemia, and smoking. She has no diabetes, kidney disease, or family hx. of early heart disease. Her medications incl…
Photo by MTAPhotos
HCTZ 25 mg daily, which she has taken for the 10 yrs., and Simvastatin 20mg daily.
Recent hx. Includes one month of progressive dyspnea on exertion, fatigue, abdominal bloating, and lower extremity edema without anginal symptoms, diaphoresis, nausea, palpations, or dizziness. Over the past week, she had a few episodes of paroxysmal nocturnal dyspnea and orthopnea.
Upon arrival in the ED, Maria was somewhat anxious.
Photo by eioua
Vital signs: 110/70, 92 regular, afebrile, saturating at 92% on supplemental oxygen. Weight was 190 lbs. BMI 32. JVP at 5cm above the clavicle and a laterally displaced point of maximal impulse, S4 and S3, 3/6 systolic murmur of mitral regurgitation. There was a hepatojugular reflux. She had a 1+ pitting edema to mid shin bilaterally.
Significant diagnostic findings included an elevated brain natriuretic peptide (BNP) at 1,100 picograms per ml. Serial troponins and other labs were negative. Chest x-ray revealed an enlarged cardiac silhouette, mild pulmonary edema without effusion, and consolidation. An echocardiogram revealed LVEF of 32%, with dilation, no wall motion abnormalities.
Photo by swishphotos
Serial EKGs were normal.
During her hospitalization, Maria received diuretic therapy with improvement in her symptoms. Her BNP dropped to 200 picograms per ml; other labs remained stable; oxygen saturation normalized on room air. At discharge, her exam demonstrated a 10 lb. weight loss with resolution of the HJR and lower extremity edema.
Photo by Stéfan
Cardiac exam was significant for ongoing lateral point of maximal impulse PMI, or apical impulse, 3/6 systolic murmur of mitral regurgitation, and resolution of the S3. The JVP was at the clavicle.
Discharge medications included Lasix 20mg daily, lisinopril 10mg daily, Simvastatin 20mg daily at bedtime, and carvedilol 3.125 mg BID. The side effects and reasons for use for each medication were reviewed.
Photo by consumerfriendly
Maria was counseled regarding the importance of smoking cessation and received a prescription for nicotine patches as well as the Colorado Quit Line. She received instructions regarding activity level; strategies to limit her intake of sodium to less than 2,000 mg and her fluid intake to less than 2 liters per day were reviewed with her.
Detailed instructions were also given to Maria regarding checking daily weights and when to notify the provider (2-3 lb. weight gain in a 24 hr. Period, worsening SOB, swelling in her legs and abdomen, chest pain, or dizziness).
Photo by dailylifeofmojo
