Case of a Patient With Dyspnea and Other Symptoms

What is the Chief Complaint?

The patient’s chief complaint is shortness of breath. The patient also noted the presence of other symptoms, such as unproductive cough, fatigue, and obstruction of breathing at night. She denies other symptoms that can be associated with shortness of breath or cough, such as chest pain, nausea, and sweating.

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Based on the Subjective and Objective Information Provided What are Your 3 Top Differential Diagnosis Listing the Presumptive Final Diagnosis First?

The patient’s complaints are consistent with three diseases, including left-sided heart failure (hypertensive heart disease), cardiogenic pulmonary edema (CPE), and myocardial infarction with systolic dysfunction.

Hypertensive heart disease is a cardiovascular condition associated with high blood pressure. According to Díez (2013), it “can be defined as the cardiomyopathy that results from the response of the myocardium to the biomechanical stress imposed on the left ventricle by the progressively increasing blood pressure” (para. 1). Left ventricular hypertrophy (LVH) associated with high blood pressure is the key indicator of hypertensive heart disease. The disease can also feature increased ventricular stiffness, arrhythmia, and systolic dysfunction (Angeli et al., 2018).

CPE is specified as an acute condition, which is based on the pathological accumulation of extravascular fluid in the lung tissue and alveoli, leading to a decrease in lung functional capacity. The increase in hydrostatic pressure of the system of the small circle of blood circulation and permeability of the capillary wall is two characteristic mechanisms of CPE. Dyspnea noted by the patient is characteristic of the given diagnosis and also accompanied by swelling and increased frequency of respiratory movements increases per minute. Shortness of breath and non-productive cough strengthen in the prone position. Therefore, despite the severity of the condition, patients tend to adopt a sitting position with fixation of the shoulder girdle likewise the given patient tried to sleep in her recliner.

Myocardial infarction with systolic dysfunction is associated with adverse outcomes such as ischemia. Dysfunction of the ventricles of the heart is a violation of the ability of the heart muscle to contract under the systolic type to expel the blood in the vessels (Ersbøll et al., 2013). Symptoms may involve non-productive cough, fatigue, uncaused muscle weakness, as well as changes in activity and the psychoemotional sphere. Depending on how well the heart is contracting, its systolic function is determined. At the same time, one should be guided by indicators obtained by the ultrasound and EKG. If the fraction is below 40 percent, then it means that the systolic function is broken, and only 40 percent of the blood enters the general blood flow, while the normal rate is 55-70 percent (Ersbøll et al., 2013).

What Treatment Plan Would You Consider Utilizing Current Evidence-Based Practice Guidelines?

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As per the American College of Cardiology Foundation/American Heart Association (ACCF/AHA), it is crucial to produce a final diagnosis using further diagnostic procedures. The patient should be referred for echocardiography and electrocardiography to determine the presence of HHD indicators such as LVH and ventricular stiffness.

Treatment Plan

The combination of several drugs is usually more effective for the treatment of heart failure and the removal of negative symptoms:

  • Diuretics should be prescribed to remove excess fluid from the body, thus eliminating edema and reducing the burden on the heart (0.5-1 g (10 to 20 mL) PO/IV per day). The adverse impact of diuretics is that they excrete magnesium and potassium from the body, the lack of which can worsen a patient’s condition (Rosenkranz et al., 2015). Therefore, the above elements should be replenished timely.
  • Antianginal drugs (beta-blockers) are to dilate blood vessels, reduce the need of the heart in oxygen and, at the same time, increase its delivery, leading to a decrease in the stress of the ventricles and pressure in the small circle of the circulation (Metoprolol from 12.5mg PO to 200mg PO per day).
  • Angiotensin-converting enzyme (ACE) inhibitors will contribute to increased coronary blood flow and lead to a decrease in the severity of myocardial hypertrophy with long-term use (enalapril 2.5 mg OP once a day with diuretics) (McMurray et al., 2014). This group of drugs dilates the blood vessels and facilitates the work of the heart for pumping blood (Yancy et al., 2013). The alternative is Angiotensin II Receptor Blockers for those patients, who are unable to take ACE (Losartan 25mg-50mg PO daily).
  • Aldosterone antagonists should be used to enhance the rate and cardiac workload (spironolactone 25mg per day).
  • Digoxin strengthens muscles, slows down the heartbeat, and reduces symptoms of systolic heart failure (3.0 to 4.5 mcg per day).

Hypertension Therapy

Controlling for high blood pressure is essential to ensure positive patient outcomes in patients with HHD (Angeli et al., 2018). Thus, if the HHD diagnosis is confirmed, the treatment plan should seek to reduce the patient’s blood pressure to a normal range. James et al. (2014) recommend using ACE inhibitors or ARBs for the management of high blood pressure in hypertensive white adults.

Lifestyle Modifications

Regardless of the final diagnosis, certain lifestyle modifications can help the patient to avoid exacerbations and will complement pharmacological treatment to make it more efficient. Firstly, it is critical to educate the patient on the importance of taking the prescribed medication and improve her knowledge of the final diagnosis. O’Conor et al. (2015) state that improving adherence to the treatment plan and the proper use of medication can have a significant positive influence on improved health outcomes.

References

Angeli, F., Reboldi, G., Trapasso, M., Aita, A., Tuturiello, D., & Verdecchia, P. (2018). Hypertensive heart disease. Web.

Díez, J. (2013). Hypertensive heart disease. Web.

Ersbøll, M., Andersen, M. J., Valeur, N., Mogensen, U. M., Fahkri, Y., Thune, J. J.,… Køber, L. (2013). Early diastolic strain rate in relation to systolic and diastolic function and prognosis in acute myocardial infarction: A two-dimensional speckle-tracking study. European Heart Journal, 35(10), 648-656.

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McMurray, J. J., Packer, M., Desai, A. S., Gong, J., Lefkowitz, M. P., Rizkala, A. R.,… Zile, M. R. (2014). Angiotensin–neprilysin inhibition versus enalapril in heart failure. New England Journal of Medicine, 371(11), 993-1004.

O’Conor, R., Wolf, M. S., Smith, S. G., Martynenko, M., Vicencio, D. P., Sano, M.,… Federman, A. D. (2015). Health literacy, cognitive function, proper use, and adherence to inhaled asthma controller medications among older adults with asthma. CHEST Journal, 147(5), 1307-1315.

Rosenkranz, S., Gibbs, J. S. R., Wachter, R., De Marco, T., Vonk-Noordegraaf, A., & Vachiery, J. L. (2015). Left ventricular heart failure and pulmonary hypertension. European Heart Journal, 37(12), 942-954.

Yancy, C. W., Jessup, M., Bozkurt, B., Butler, J., Casey, D. E., Drazner, M. H.,… Johnson, M. R. (2013). 2013 ACCF/AHA guideline for the management of heart failure: Executive summary. Circulation, 128(16), 1810-1852.

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