Clinical Scenario:
Mrs. Smith is a 60 year old Asian who was driven to the emergency room by her daughter who noticed that her mother sounded short of breath oh the telephone. The patient missed a routine appointmentshe had at the clinic earlier in the week because she didn't feel well enough to go. Upon questioning Mrs. Smith says she is fatigued and nauseated -most of the time-. She is havingtroublesleepingand reports shortness of breath when doing light housework. She has also developed swellingin her ankles and hands in the past 2 weeks.
PMH: Hypertension for20 yrs, myocardial infarction 5 years ago, DM diagnosed 3 months ago (prescribed diet and exercise and scheduled for follow-up this week but pt. missed appt)
Current medications: Aspirin 81 mg„ metoprolol 12.5 mg BID, diltiazem ER 120 mg., 0TC analgesics for arthritis as needed
Allergies: NKDA
SH: widow, quit smoking after her M|, occasional alcohol use. Retired cook.
FH: Mother and aunt have diabetes, Father died in MVA
ROS: {pertinent negatives and positives) eiiminated sweets from her diet, walked 20 minutes 3 times a week for 3-4 weeks butthen stopped, no fever or chills, no palpitations, chest pain, orthopnea or paroxysmal nocturnal dyspnea, nocturia once nightly.
Exam BP 155/90, HR 75, Resp 18, Height 5'3-, Weight 160 lb,
General: well-developed, well-nourished woman appearing her stated age in ho acute distress
Neck: jugular venous distention to 7 cm
Lungs: bibasilar crackles
CV: regular rate and rhythm with S3 gallop, no murmur
Abdomen : no hepatosplenomegaly or ascites
Extremities: 1+ pedal edema bilaterally
LAB: random glucose 210 mg/dL, HgbAlC 8%, Na 13Q mEq/L, K 4.8 mEq/L, Mg 1.8 mEq/L, BUN 30 mg/dL, Creatinine 1.7 mg/dL, CBC within normal limits, Urinalysis glucose 2+but otherwise negative, troponin 0.09 ng/mL, B-type natriuretic peptide840 pg/mL, TSH 2.0 microlU/mL
Chest x-ray shows a slightly enlarged heart and bibasilarpleural effusions
Echocardiogram shows left ventricular ejection fraction 35% and no significant valvular disease
Questions:
1. Based on the information given, what is your diagnosisforthis patient and why shouldshebe admitted to the hospital?
2. Whattreatment would you initiate to control the symptoms responsible for her admission? What medication could improve her prognosis?
3. Howdoes the admitting diagnosis affect management of her other comorbidities?
4. What are the goals of therapy for each of her diagnoses? What adjustments in her medications would you recommend to help her achieve these goals?
5. What non-pharmacologic measures and diet considerations could helpthis patient reach the goals stated in #4?