Shortness Of Breath Flashcards
ED
64 y/o M with 2 mo hx of Progressively increasing shortness of breath. Condition has acutely worse and over two days and now has SOB at rest. Symptoms slightly relieved when sitting upright. No chest or abdominal pain. Mild cough with deep inspiration, occasional pink fluffy sputum. Weight gain over past six months. Easy fatigability, leg swelling, decreased appetite. No F/C/N/V/HA. BM reg, no urinary complaints. Diet has consisted of canned foods since wife passed away nine months ago.
Past medical history includes HTN and T2DM x 19 years. MI six years ago treated with thrombolytic therapy. HLD.
Medications: metoprolol, lisinopril, glyburide, Simvastatin, aspirin, isosorbide dinitrate. Patient compliant with medications.
1 ppd x 40 years. Rec etoh on weekends. Retired. Lives alone.
What’s your approach?
Elevate HOB Continuous pulse ox, stat Continuous O2 IV access stat Telemetry 12-lead EKG stat
Initial findings:
Pulse ox 89% RA
NSR 70 bpm. Old q wave in inferior leads, no significant changes.
What PE do you want?
General HEENT/neck Heart Lungs Abd Extremities
PE findings:
Mild resp distress
Mod JVD
B/l BS decreased with bibasilar crackles
RRR. S1 S2. S3 gallop
Soft RUQ abd tenderness. Liver 1 cm below rob. No free fluid
3+ b/l pitting edema to knee. No calf tenderness. No cyanosis.
What’s your approach to case?
DDx: progressive (ch) SOB:
COPD
Cardiomyopathy.
Presentation suggestive of acute decompensated HF
(Likely d/t high Na intake from dietary noncompliance.
What orders do you want?
CXR, PA and lat, stat CBC with diff stat BMP stat Trop I stat and q 6h x2 LFTs stat NT-pro BNP stat Lasix IV stat and continuous
Results of orders: CXR consistent with b/l pulmonary edema CBC and trop nml Na 138 k 4 Glucose 380 BNP 1800
What do you want to order?
Admit to floor with telemetry Up at lib Low-salt, low-cholesterol, diabetic diet Fluid restriction I/O, daily weights Continue home meds except glyburide PO KCL continuous as long as lasix Start regular insulin sliding scale ACHS Accu checks ACHS Give 10U regular insulin now Lovenox subQ daily for DVT Ppx BMP daily HbA1C routine Lipid profile routine Echo to assess LV fxn
Day 2 findings:
TTE: mod LVH,EF 40%, abnl diastolic fxn
Consider converting IV lasix to PO
Is patient ok for DC? (Improved dyspnea and peripheral edema)
Assess need for O2 therapy goal sats 92-96%. Wean O2 for sats>92%
What do you need to consider at time of DC?
Patient education Cardiac rehab Smoking and etoh cessation Regular exercise Dietary and medication compliance
Follow up In 1 week
Clinical discussion:
CHF is a clinical diagnosis, imaging and labs are used to confirm.
Initial treatment includes IV loop diuretics w/monitoring of renal fxn and electrolytes
Acute respiratory insufficiency should be treated with supplemental O2 and if needed noninvasive positive pressure ventilation.
Refractory systolic Hf may need temporary IV inotropic support (dobutamine, milrinone)
Long term use of ACEi/ARBs, BBs, and mineralocorticoid receptor antagonists reduce mortality in patients with ch systolic HF. Continuing these meds during an episode of acute decompensated HF depends on whether the patient was taking them prior to presentation and HD status during the decompensated state
Dx: acute exacerbation of heart failure (systolic and diastolic)
