6531 Week 4 iHuman Case Study Answers – Shortness of Breath

6531 Week 4 iHuman Case Study Answers – Shortness of Breath (SOB)

Reason for Encounter

Shortness of Breath (SOB)

History of present illness (HPI)

A 60 year old known hypertensive, hyperlipidemia, and CAD female presents for evaluation of worsening shortness of breath (SOB) for the last two weeks, a dry cough, chest pain, and worsening fatigue. The SOB is there throughout the day, it worsens with lying flat on her back or moving around. The dry cough started suddenly a week ago, it worsens with sleeping or lying down, it is constant throughout the day and night, but worsens during the night hence, she cannot sleep. The chest pain started gradually three days ago, it is localized in the middle of the chest, is intermittent and described as achy. The pain worsens with coughing or walking around for too long, is mildly relieved with resting and has a severity of 4 out of 10. The fatigue also started three days ago, it worsens with longstanding, movement and activity. She acknowledges an unintentional weight gain of 8 pounds within the last 2 weeks and acknowledges that her “socks are a bit more snug”. She denies coughing blood, sputum production, fevers, chills, dizziness, runny nose, unusual heartbeats, nausea and vomiting.

History Questions

How can I help you today?
Do you have any other symptoms or concerns we should discuss?
When did you first notice feeling short of breath?
How long does your shortness of breath last?
How severe is your shortness of breath?
Are you short of breath at rest?
Are you short of breath when lying down?
Are you short of breath?
What are the events surrounding the start of your cough?
When did your cough start?

Physical Exam

Cognitive status
Blood pressure
Pulse
Respiration
Temperature
SPO2
Inspect skin overall
Auscultate carotid arteries

Case Findings

Increasing shortness of breath x 2 weeks
Cough, non-productive, worse with activity and lying down
Chest pain x 3 days
8 pound weight gain over 2 weeks
Coronary artery diseases (CAD), hyperlipidemia, and hypertension (PMH)
20-pack year smoking history (SH)

Problem Statement

The patient is a 60-year old female presenting for evaluation of a 2-week history of worsening shortness of breath (SOB), a dry cough that worsens with lying down and activity, and a three day history of worsening fatigue and chest pain. Patient also reports unintentional 8 pound weight gain in the last 2 weeks. PMH is significant for hypertension, hyperlipidemia, and coronary artery disease (CAD). Social history is significant for heavy alcohol intake, tobacco smoking (20 pack years). Physical exam demonstrates +1 peripheral edema, decreased perfusion of the lower extremities, elevated JVP, tachycardia (118bpm), displaced PMI, S3 gallop, bilateral crackles on the lower lobes on lung auscultation.

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Primary Diagnosis

Congestive Heart Failure (CHF) ICD10 I50.9– CHF is a clinical syndrome resulting from functional or structural impairment of the ejection of blood or ventricular filling. Its major cause is coronary heart disease (CAD) which results to heart ischemia (Heidenreich et al., 2022). However, there are other causes such as hypertension, valvular heart disease, congenital heart disease, and arrhythmias. Patients present with signs and symptoms of organ hypo-perfusion and the most reported symptom is shortness of breath (SOB). Additional symptoms include exertional fatigue, chest pain, a dry/recumbent cough, anorexia, and lower extremity edema (Heidenreich et al., 2022). This patient’s clinical presentation of SOB, dry cough, fatigue, and chest pain, a PMH of CAD and poorly controlled hypertension, and physical exam findings of peripheral edema, reduced perfusion of the lower extremity, tachycardia, S3 gallop, and a displaced PMI is consistent with the clinical spectrum of CHF. Heavy alcohol intake and a BMI 31.5 are additional risk factors.

Guideline used

I used the guidelines provided by the American Heart Association (2022) to diagnose and manage this patient. Heidenreich et al., (2022) highlight that history and physical exam are the cornerstone in assessing and diagnosing heart failure supported and confirmed through electrocardiography, laboratory testing and cardiac imaging. Management involving both pharmacological and non-pharmacological interventions should be implemented. Non-pharmacological interventions include dietary sodium restriction, exercise training, smoking cessation, stress management, alcohol moderation, weight management, and regular screening to manage risk factors Heidenreich et al., (2022). Recommended first line pharmacological agents include; hypertension management with diuretics, renin angiotensin inhibitors/receptor blockers, or calcium channel blockers, lipid management with statins, and antiplatelet therapy with low dose aspirin Heidenreich et al., (2022). This patient’s diagnosis of heart failure was made through a history and physical exam assessment and confirmed with both imaging (electrocardiogram and chest x-ray) and laboratory (brain natriuretic peptide) test. He was managed with both pharmacological and non-pharmacological interventions involving cardiac monitoring, statins, optimization of the antihypertensives (switched ACE inhibitors and added a beta blocker), and spironolactone. Recommendations for to continue with a low sodium diet, enroll to a weight loss program with daily monitoring, and support for smoking cessation were made. She was also referred to a nutritionist for further dietary evaluation and management and a cardiology for advanced cardiac evaluation, management, and possible enrollment into a cardiac rehabilitation program.

Labs, Procedures, Diagnostic Testing, Referrals, & Codes Used for Todays Visit

Office visit with moderate complexity– 99214

Medications

Stop lisinopril for hypertension
Start valsartan 24mg PO 12 hourly after a 36-hour washout to prevent angioedema.
Start furosemide 20mg PO 24 hourly (Heidenreich et al., 2022).
Carvedilol 3.125mg PO 12 hourly
Aspirin 81mg PO 24 hourly (Heidenreich et al., 2022).
Simvastatin 20mg PO 24 hourly at bedtime
Spironolactone 12.5mg PO 24 hourly

SDOH Plan

Provide educational resources on congestive heart failure
Evaluate and address emerging social needs regularly to promote overall well-being
Provide educational resources on nutrition to promote weight loss and alcohol cessation.

Patient risk factors

The 60 year old patient has a PMH of coronary artery disease (CAD), hypertension, BMI 31.5 (obesity), and hyperlipidemia which are all risk factors of CHF. The patient’s most significant risk factor is underlying CAD which causes ischemic heart disease resulting to inadequate/lack of blood supply to cardiac muscles, reducing the ejection fraction (Heidenreich et al., 2022). Poorly controlled hypertension contributes to CHF through mechanical stress where neurohormonal changes and increased afterload increase ventricular mass. Obesity (BMI 31.5), although mostly a risk factor in patients aged 40 years and younger, also contributes to heart failure through degradation of natriuretic peptides by the adipose tissue.

Follow-up instructions

Follow-up with your primary care provider in 1-2 weeks to review symptoms and evaluate response to medications.
Follow up with cardiology and nutrition in 1 week for further cardiovascular evaluation and dietary management. Referral has been placed today and someone from Community Health Network will contact you to schedule the appointments. If you do not hear from them within 48 hours, contact them via (317) 355-7775 and request to be directed to nutrition & cardiology for inquiries.
Seek immediate emergency medical care when you experience any of the following symptoms; worsening SOB, worsening cough, chest pain, chest discomfort, irregular heartbeat, moderate-severe headache, or visual disturbances.

References

Fathima, S. N. (2021). An Update on Myocardial Infarction. Current Research and Trends in Medical Science and Technology, 1.

Freund, Y., Cohen-Aubart, F., & Bloom, B. (2022). Acute pulmonary embolism: a review. Jama, 328(13), 1336-1345.

Gottlieb, D. J., & Punjabi, N. M. (2020). Diagnosis and management of obstructive sleep apnea: a review. Jama, 323(14), 1389-1400.

Heidenreich, P. A., Bozkurt, B., Aguilar, D., Allen, L. A., Byun, J. J., Colvin, M. M., & Yancy, C. W. (2022). 2022 AHA/ACC/HFSA guideline for the management of heart failure: a report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Journal of the American College of Cardiology, 79(17), e263-e421.

Hopkinson, N. S., Molyneux, A., Pink, J., & Harrisingh, M. C. (2019). Chronic obstructive pulmonary disease: diagnosis and management: summary of updated NICE guidance. Bmj, 366.

Louis, R., Satia, I., Ojanguren, I., Schleich, F., Bonini, M., Tonia, T., & Usmani, O. S. (2022). European Respiratory Society guidelines for the diagnosis of asthma in adults. European Respiratory Journal, 60(3).