Presumptive and differential diagnoses

The chief complaint stated in this case scenario is increasing shortness of breath as well as nonproductive cough over the last month.

Presumptive and differential diagnoses

The subjective findings provided in this case scenario are the increased shortness of breath the patient is feeling, the fact she has to sleep elevated on a pillow at night to sleep better, but denies chest pain, nausea or sweating. The objective findings include a blood pressure of 160/100, a pulse of 100, a respiratory rate of 16, and she is afebrile. On examination, there is distant air sounds, has late inspiratory crackles in both lower lobes, S1 and S2 sound distant, and an S3 can be heard on the apex of the heart.

The presumptive final diagnosis is congestive heart failure. This condition is described as “a complex clinical syndrome characterized by the reduced ability of the heart to pump and/or fill with blood” (Savarese & Lund, 2017). When a patient is diagnosed with heart failure, the cardiac output that is pumped is inadequate to meet the metabolic demands of the heart. Different classifications of heart failure exist and depends on the progress of the disease. Signs and symptoms associated with this condition include exertional dyspnea and/or dyspnea at rest, orthopnea, chest pain, pressure or palpitations, tachycardia, fatigue and weakness, rales, wheezing, S3 gallop, hepatojugular reflux and more (Dumitru, 2022).

A differential diagnosis to congestive heart failure is cardiogenic pulmonary edema. This condition is defined as pulmonary edema that is due to the increased capillary hydrostatic pressure, which is secondary to the elevated pulmonary venous pressure. It is more specifically defined as the accumulation of fluid due to the cardiac dysfunction. Patients with this condition have clinical features of left heart failure. Symptoms include extreme breathlessness, anxiety, with the feeling of drowning. Common presentation includes shortness of breath, as well as profuse diaphoresis, dyspnea on exertion, orthopnea, as well as paroxysmal nocturnal dyspnea. Additionally, cough is a common symptom which can represent worsening pulmonary edema. Pink and frothy sputum may also be seen with advanced disease (Sovari, 2020).

Another potential differential diagnosis for this patient is acute kidney injury, also known as acute renal failure. It is defined as an abrupt, or a rapidly declining of the renal filtration function. Typical lab values associated with his condition include a rise in serum creatinine concentration or by azotemia. Three categories of acute kidney injury exist, prerenal, intrinsic as well as postrenal. Multiple signs and symptoms are seen with this condition, which include skin problems, eyes and ears, cardiovascular system, abdominal as well as pulmonary problems. Cardiac issues include irregular rhythms, murmurs, pericardial friction rubs or increased jugulovenous distention, rales, and S3. Pulmonary wise, rales and hemoptysis may be observed as well (Workeneh, 2022).

Treatment plan

The treatment plan for congestive heart failure is composed of many modalities including nonpharmacologic, pharmacologic as well as invasive strategies in order to limit and hopefully reverse the symptoms.

A first nonpharmacological therapy includes dietary sodium and fluid restriction. Along with that, is physical therapy as appropriate, and paying close attention to the weight gain of the patient. Some pharmacological therapies may include using diuretics, vasodilators, inotropic agents, anticoagulants, beta blockers, ACE inhibitors, ARBS, CCBs, digoxin, nitrates, B-type natriuretic peptides, I(F) inhibitors, angiotensin receptor-neprilysin inhibitors (ARNIs), soluble guanylate cyclase stimulators, sodium-glucose cotransporter-2 inhibitors (SGLT2Is), as well as mineralocorticoid receptor antagonists (MRAs) (Dumitru, 2022).

Some invasive therapies for congestive heart failure include electrophysiologic interventions. Some of these include cardiac resynchronization therapy (CRT), pacemakers, as well as implantable cardioverter-defibrillators (ICDs). Some revascularization procedures include coronary artery bypass grafting (CABG) along with percutaneous coronary intervention (PCI). Additional invasive therapies include valve replacement or repair, as well as ventricular restoration (Dumitru, 2022).

When medications and previous treatments have failed or the condition has progressed to end-stage heart failure and the prognosis is poor, heart transplantation may be an option. Mechanical circulatory devices, such as ventricular assist device (LVAD) and total artificial hearts (TAHs) can act as a bridge to a heart transplant (Dumitru, 2022).

It is also important to note that heart failure may come with comorbidities. Coronary artery disease, leading to reduced ejection fraction and angina can coexist in such patients. Valvular heart disease is another comorbidity as it can be the underlying etiology or be an aggravating factor. Sleep apnea is another condition that can develop with congestive heart failure and should be treated aggressively by providing CPAP machines. Anemia may also develop as a reflection of the degree of the disease. Cardiorenal syndrome may also be significant. It “reflects advanced cardiorenal dysregulation manifested by acute heart failure, worsening renal function, and diuretic resistance” (Dumitru, 2022). Lastly, atrial fibrillation may be diagnosed in patients with heart failure, and the two conditions may adversely affect one another.

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