Discussion Responses

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Practicum class: #1…… What is the chief complaint? “increasing
Shortness of breath and have been coughing for the past month”

Based
on the subjective and objective information provided what are your 3
top differential diagnosis listing the presumptive final diagnosis
first?

Left sided heart Failure (I50.1)- the heart muscle on the
left side is diminished and the pump is failing (Guan et al, 2021)
Symptoms are awakening at night with SOB or when lying down, chronic
cough/wheezing, fatigue, fluid retention, edema, decreased appetite,
elevated BP, rapid HR, and weight gain (Guan et al, 2021). The prognosis
of heart failure depends on the cause of the condition and the severity
of symptoms. Some causes of Left sided heart failure are cocaine use,
DM, ETOH, HTN, sleep apnea, cardiomyopathy and tobacco use (Guan et al,
2021). The patient’s complaints of SOB and crackles noted via
auscultation

Pneumonia (J18.9)- symptoms may vary; symptoms of
chest pain during cough, confusion, fatigue, cough, fever, fatigue,
nausea and SOB (). This patient most likely gotten pneumonia from a
bacteria or virus (COVID).

COVID (U07.1)- If this patient was
seen today, she would have been tested for COVID. She could have
developed COVID a month ago when her coughing started and now developed
complications. Symptoms of COVID vary in every patient. Some symptoms
include: fever, dry cough, fatigue, body aches, rash, chest pain, loss
taste/smell, sore throat and diarrhea (Saunders, 2020).

What treatment plan would you consider utilizing current evidence-based practice guidelines?

According
to Up To Date, an ECG, labs (BNP, Cardiac enzymes, CBC and LFT) and
chest xray should be ordered when heart failure is considered (2021).
This patient also needs a STAT referral to cardiology. I would start
with Lasix 10mg PO qday and follow up in 3 days to check if shortness of
breath and swelling improved. An ACE inhibitor or an ARB is recommended
for patients with heart failure (Up to Date, 2021). Regular exercise,
limited fluid intake, low sodium diet and no alcohol is recommended
(Dunphy, 2017). Encourage patient to weigh daily to check fluid
retention and notify provider if 3lb weight gain in 24 hours (Dunphy,
2017). I would possibly send this patient to the ED, depending on how
the patient looked in office (degree of SOB) and her oxygen saturation
<92 % (Dunphy, 2017). The cardiologist would order further testing
like an echocardiogram to diagnose CHF and identify how well the heart
is pumping.

Practicum class: #2…… What is the chief complaint?

“Increasing shortness of breath and nonproductive cough over the last month.”

Based
on the subjective and objective information provided what are your 3
top differential diagnosis listing the presumptive final diagnosis
first?

Left-sided heart failure (ICD-10: I50.1): Patient states
she is having increasing shortness of breath & nonproductive cough x
1 month, as well as increased fatigue. Since the fluid is backing up
into her lungs, she has to sleep upright in her recliner to breath
comfortably. This causes the crackles in the base of her lungs. The
patient also has an audible S3 over the apex, which is often a sign of
heart failure.

Pericardial effusion (ICD-10: I31.3): Patient has
a medical history positive for hypertension and coronary artery
disease. In clinic, her blood pressure was 160/100 which puts her in the
category of Stage 2 Hypertension. Symptoms of pericardial effusion can
include, but are not limited to, chest pain, shortness of breath,
tachycardia, and tachypnea.

Pneumonia (ICD-10: J18.9): With
auscultation, crackling is heard in both lower lobes. Patient is also
complaining of increasing shortness of breath and cough x 1 month.

What treatment plan would you consider utilizing current evidence-based practice guidelines?

Heart
failure is a condition in which cardiac output is insufficient to meet
the body’s metabolic demands, with left-sided being the most common type
of heart failure. Factors that increase the risk of heart failure
include infectious disease, obesity, anemia, the physiologic stress of
pregnancy, diabetes mellitus, chronic renal insufficiency, myocarditis,
cardiomyopathies, valvular disorders, CAD, dysrhythmias, thyrotoxicosis,
PE, sleep apnea, alcohol abuse, substance abuse, and chemotherapeutics
(Dunphy et al., 2017). The most common cause of heart failure includes
coronary artery disease, a history of a myocardial infarction, and
chronic hypertension.

The treatment plan would include proper
diagnostic testing, including a CBC, CMP, and BNP (with a value greater
than 500 pg/mL being highly indicative of HF). A chest x-ray may show an
alteration in cardiac silhouette as evidenced by a change in cardiac
size and shape, a change in the cardiothoracic ratio, and specific
cardiac chamber enlargements (Dunphy et al., 2017). Although an ECG may
help diagnose underlying causes of HF, such as dysrhythmias or an MI, an
echocardiogram is the diagnostic test commonly used to confirm heart
failure after noting a demonstrable elevation of BNP (Dunphy et al.,
2017). A right-sided heart cath is also helpful in measuring
intracardiac pressures.

When considering medication management
for HF, treatments are needed that will decrease cardiac workload,
decrease volume overload, optimize LV function, correct ventricular
dyssynchrony, reduce mortality, and control the ventricular rate or
convert atrial fibrillation to a sinus rhythm if present (Dunphy et al.,
2017). Studies have shown that ACE inhibitors, diuretics, implantable
pacemakers and defibrillators, and lifestyle modification have greatly
reduced mortality rates for individuals living with heart failure
(Berliner, Hanselmann, & Bauersachs, 2020).

ACE inhibitors
(ACEIs) are indicated for all patients with HF unless the patient has an
intolerance or an adverse effect. ARBs may be used as an alternative to
ACEIs as they have a lower risk for cough and angioedema. Vasodilators
and nitrates may also be used as alternatives. Recent evidence-based
research has shown that the use of beta blockers is highly useful in
heart failure individuals, and that studies have shown they reduce the
rate of hospital readmission (Kruik et al., 2020) With progressed heart
failure, spironolactone has been shown to be of benefit as well. For
inpatient end-stage heart failure, intravenous inotropic agents such as
dopamine, dobutamine, and milrinone may be used as well (Dunphy et al.,
2017).

According to Dunphy et al. (2017), supplemental to the
medication management, heart failure patients will also need the
following education:
Regular exercise should be encouraged
Dietary sodium should be restricted to 2 g per day
Limitation of fluid intake
Discouragement of alcohol intake
Record taily weight and notify provider if weight gain of 3 lbs in 24 hours or 5 lbs in 1 week

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