Congestive Heart Failure

Case Study

Madeline Brunner is an 84-year-old woman that you are visiting in her facility for wound care. She developed a pressure ulcer during her hospitalization for a left total hip replacement. She also has osteoarthritis (OA) in her right hip and plans a right hip replacement soon. The wound and her hip are doing well, but she complains that she is not feeling well today and thinks she is “coming down with a cold.” She has had a nonproductive cough with increased shortness of breath for the past two days and has needed to sleep in her recliner because she is uncomfortable lying in her bed. Her appetite has been lacking, which she attributes to constipation with the narcotic prescribed after her surgery. She has taken ample quantities of beef and chicken broth only for the past few days due to an upset stomach. Typically, Madeline can walk up and down her hall with the physical therapist without difficulty. Still, yesterday she could only walk about 10 ft before needing to rest due to shortness of breath. Madeline lives alone in an assisted living facility and has two adult daughters who provide social support and manage her finances. She manages her medications and shows you her pillbox, which is correctly set up and can explain each medication’s purpose. She does not smoke. Her past medical history includes the following:

Coronary artery disease (CAD) with MI in 2003
Congestive heart failure (CHF)
Osteoarthritis (OA) hips s/p left hip replacement six months ago
Hypertension (HTN)
Current medications taken orally include the following:

furosemide (Lasix) 20 mg, oral, every am
potassium chloride (K-Dur) 20 mEq, oral, every am
metoprolol (Lopressor) 25 mg, 0.5 tabs, oral, BID
lisinopril (Prinivil) 10 mg, oral, every am
acetaminophen/ hydrocodone (Vicodin) 500/5 mg, 1 tab oral, TID
aspirin (ASA) 81 mg, oral, daily
simvastatin (Zocor) 20 mg, oral, every pm
ibuprofen (Advil) 400 mg, every 6 hours, prn pain.
Seasonal flu shot was given in late October last year.

On exam, you take the following vital signs:

BP 110/62; Pulse 102; Respirations: 22; O2 sat 92%; Temp 97 Oral

You also document:

Heart sounds: S1S2 with S3 gallop, no murmurs or rubs

Lung Sounds: Crackles in bases bilateral

ABD: soft, non-tender, distended with positive hepatojugular reflux.Bowel sounds normal X 4 quadrants

Extremities: Capillary refill <2 seconds, 2+ edema in feet and ankles bilaterally

What are the pertinent findings of your physical exam? Explain the pathophysiology of each of these findings.
What do you suspect may be causing Madeline’s symptoms?
What may have precipitated this problem?
Does Madeline demonstrate symptoms of right- or left-sided heart failure, or both? Explain.
How is congestive heart failure (CHF) diagnosed?
Based on what you know about Madeline, what is her New York Heart Association (NYHA), Functional class, at baseline? What is her baseline American College of Cardiology/ American Heart Association (ACC/AHA) stage of heart failure?
What action should you take at this point?
Madeline’s primary care physician orders a serum BNP, a chest X-ray, a 12 lead EKG, and a cardiac echocardiogram. Her physician also increases the doses of her furosemide (Lasix) and potassium chloride (K-Dur).What is the purpose of these diagnostic tests?
How can you help Madeline to prevent future CHF exacerbations and hospitalizations related to this condition?

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