Case
Chief Complaint
"Why can't we get my weight stabilized?"
HPI
A 67-year-old man who presents to the ED with shortness of breath and bilateral lower extremity edema. He reports his symptoms started approximately 3 weeks ago. He noted that he was gaining about 1-2 lb daily and gained approximately 25 lb of weight over the month prior to admission. He attempted to use his albuterol/ipratropium MDI for relief of his shortness of breath symptoms at home without improvement. As his symptoms of edema and shortness of breath worsened, he called his primary care physician, who increased his furosemide dose over the phone to 80 mg twice daily more than 1 week ago. In the ED, he was noted to be hypoxic with an increased oxygen need from 2 to 4 L by nasal cannula. He was given one dose of IV furosemide 80 mg with minimal improvement in his symptoms and then admitted to the medicine service for further evaluation and management.
PMH
• CAD (s/p STEMI 10 years ago)
• COPD × 5 years
• HFpEF × 6 years (last hospitalization 4 months ago)
• Dyslipidemia × 15 years
• HTN × 25 years
• Type 2 DM × 5 years
FH
Father is alive at age 88 with type 2 DM; mother is alive at age 87 and has HTN and dyslipidemia; two brothers (age 60 and 64) are alive, and both have type 2 DM and HTN.
SH
History of tobacco use (40 pack-year history) but quit 5 years ago. Denies any alcohol or substance abuse. Lives alone.
Meds
• Albuterol/ipratropium MDI, two puffs inhaled Q 6 H PRN
• Aspirin 81 mg PO daily
• Clopidogrel 75 mg PO daily
• Lisinopril 40 mg PO daily
• Carvedilol 12. 5 mg PO BID
Furosemide 80 mg PO BID (previously 40 mg PO BID)
• Amlodipine 5 mg PO daily
• Metformin 1000 mg PO BID
• Nitroglycerin 0. 4 mg SL q 5 minutes PRN chest pain
• Potassium chloride 20 mEq PO daily
• Rosuvastatin 20 mg PO daily
• Seasonal influenza vaccine (previous year)
All
NKDA
ROS
Gen
Patient reports a recent 25-lb weight gain over the past month
CV
No complaints of chest pain
Resp
Reports an increase in shortness of breath from baseline over the last month and dyspnea on exertion
GI
No recent changes noted in bowel habits
GU
No complaints
MS
No complaints of MS pain or weakness
Neuro
No complaints
Physical Examination
Gen
Patient with 25-lb weight gain over past month with increased shortness of breath
VS
BP 150/82, P 64 (regular) , RR 26, T 36. 9°C; Wt 102 kg (usual weight 90 kg) , Ht 5′10′′, oxygen saturation of
95% on 4-L nasal cannula
Skin
Chronic venous stasis changes on bilateral lower extremities and 3+ edema to the knees bilaterally
HEENT
PERRLA, EOMI, fundi were not examined. Normocephalic, atraumatic. Nasal cannula in place.
Neck
(+) JVD at 30° (6 cm) No carotid bruit is appreciated. Nolymphadenopathy or thyromegaly.
Lungs/Thorax
Respirations are even. Crackles noted in the bilateral lung bases.
Heart
RRR. No murmurs, rubs, or gallops.
Abd
Obese with a nontender, nondistended abdomen; hypoactive bowel sounds
Genit/Rect
Guaiac (-) , genital examination not performed
MS/Ext
3+ pitting pedal edema bilaterally; radial and pedal pulses are of poor intensity bilaterally; grip strength
even
Neuro
A&O × 3; CNs intact; DTR intact
Labs:
Na 138 mEq/L
Hgb 15. 3 g/dL
Mg 1. 7 mEq/L
CK 20 IU/L
K 4. 0 mEq/L
Hct 47. 2%
Ca 9. 1 mg/dL
CK-MB 0. 8 IU/L
Cl 103 mEq/L
Plt 298 × 103/mm3
AST 60 IU/L
PT 12. 6 s
CO2 26 mEq/L
WBC 6. 4 × 103/mm3
ALT 60 IU/L INR 1. 1
BUN 30 mg/dL
Troponin I 0. 5 ng/mL
Alk phos 80 IU/L
TSH 1. 12 mIU/L
SCr 1. 2 mg/dL
GGT 24 IU/L
A1C 7. 5%
Glucose 108 mg/dL
T. bili 0. 2 mg/dL
BNP 2000 pg/mL
ECG
Sinus rate of 66; QRS 0. 08; no ST-T wave changes; low voltage
CXR
PA and lateral views show evidence of interstitial edema and some early alveolar edema.
Assessment
Decompensated heart failure with pulmonary and lower extremity edema
CLINICAL COURSE
The patient was admitted to a telemetry unit. The patient has a known history of HFpEF (EF 52%) per an echocardiogram from 6 months ago. A 2D echocardiogram was obtained today to evaluate the patient's current LV and valvular function. Results revealed evidence of impaired ventricular relaxation and elevated left atrial filling pressures consistent with grade III diastolic dysfunction. EF was estimated at 53%; there was no evidence of mitral stenosis or pericardial disease. A dilated inferior vena cava suggests increased right atrial pressure. Moderate pulmonary HTN is evident.
Can you make a pharmacotherapy care plan base on the following format?
1. MEDICAL PROBLEM LISTS
2. CURRENT DRUG REGIME
3. DRUG THERAPY PROBLEMS
4. THERAPY GOALS
5. THERAPEUTIC RECOMMENDATION
6. RATIONAL
7. THERAPEUTIC ALTERNATIVES
8MONITORING