Congestive Heart Failure
Patient presentation:
T.A., a 70 year old female presented to the emergency department with a complaint of shortness of breath that had become progressively worse over the past two days. The patient had palpitations; labored, shallow and increased rate of breathing with use of accessory muscles; crackles heard over bilateral lung bases; a non-productive cough; ankle edema and anxiety. She confirmed having a past medical history of diabetes, obesity, hypertension, heart attack one year ago and smoking (quit after heart attack). Initial vital signs were: temp 98.7, heart rate: 111, blood pressure: 140/80 respirations: 30, O2-Sat: 88 on room air.
Differential list:
congestive heart failure, pleural effusion, pneumonia, COPD.
Diagnosis:
The patient was immediately placed on a non-rebreather mask and IV access was obtained. A stat EKG was done, which showed sinus tachycardia. Laboratories were drawn which included: a CBC, basic metabolic panel, a set of cardiac enzymes and BNP level. A stat chest x-ray was also done, which portrayed an enlarged cardiac silhouette and bilateral pleural congestion. The laboratory results were significant for an elevated BNP level of 900. The rest of the results were within normal limits. Based upon clinical presentation and diagnostic findings, the diagnosis of congestive heart failure was made.
Treatment:
The patient was placed on cardiac monitoring and given a dose of Lasix® 40mg IV push for one dose. Oxygen supplementation continued via a non-rebreather mask. A 2D-echo was ordered to evaluate the size and function of the heart (ejection fraction). In addition, orders for strict intake and output monitoring and water restriction of 1 liter/day were set. The patient was admitted to a telemetry floor for continuous cardiac monitoring.
Outcome:
The patient was discharged home after 3 days in the hospital following adequate treatment and response. Discharge medications included: Lasix®, digoxin, potassium supplementation, and Diovan®. Instructions included monitoring of daily weights and lower extremity edema, restriction of fluids and salt in diet, and follow-up with primary care physician or cardiologist.