SOAP: Congestive Heart Failure Case



SOAP: Congestive Heart Failure Case

Subjective

Patient's Name: SA

Patient and Setting: SA, a 68 years old woman in the emergency department.

The compliant: for the past several years, the patient wakes up short of breath. Recently the patient cannot even walk to the mailbox without being exhausted. Her legs have started to swell and she has gained 15 pounds in the past coupe, of weeks. Present Illness: SA complains fatigues and dyspnea for several months, she gave up exercising for about 2 months ago because of a recent diagnosis of osteoarthritis and the fact that she gets tired walking. She coughs with sputum and feels fatigues and cannot perform her usual activities for the daily living, she also noted BLE edema for several weeks. However she denies chest pain. Medical History: CAD and HTN diagnosed at the age of 50, TEDM diagnosed at the age of 63 and OA diagnosed at the age of 65.

Surgical History: non contributory

Social and Family History: Mother: HTN; father: died at the age of 65 S/P. Tobacco: quit × 10 Years; 40 pack-year history. Currently; she lives with her husband who is retired mechanic, she has 3 children and 3 grandchildren.

Medication: daily HCTZ 25 mg PO, Simvastatin 40 mg PO at bedtime, Celecoxib 200mg BID.

Allergies: Enalapril

Objective

BP 110/78, HR 55 BMI 26.5, creatinine ~ 29 mL / min, 70 kg of body weight (IBW 55 kg), significant SOB, + JVD, diminished breath sounds, S3 gallop, PMI has been moved down and sideways, 2 + edema of the knees slightly elevated AST / ALT, Hct 34%, BNP 1263, sinus bradycardia, ventricular rate 53, the QT / QTc 470/453 is an ECG, an EF of 38% hypokinesia, and the lower front hypokinesia ECHO.

Pertinent Laboratory Tests, Serum Drug Concentrations, and Diagnostic Tests

Cl 100 (100)

Glucose 8.1 (145)

A1c 7.6 %

Mg 0.85 (1.7)

WBC 6.5 × 109 (6.5 × 103)

K 4.3 (4.3)

Hgb 140 (14)

Hct 0.34 (34)

Ca 2.3 (9.0)

BNP 1263 pg/mL

PO4 1.1 (3.3)

T Bili 15.4 (0.9)

Plts 290 × 109 (290 × 103)

Fasting

LDL 2.3 mmol/L (90 mg/dL)

Total cholesterol 4.65 mmol/L (180 mg/dL)

CXR: Positive cardiomegaly

Triglycerides 1.46 mmol/L (130 mg/dL)

HDL 1.55 mmol/L (60 mg/dL)

Urinalysis: Negative

ECG: ventricular rate 53, QT/QTc 470/453

Assessment

Problem 1: Onset heart failure. It is important to admit the patient to hospital for work up of new onset heart failure. The patient may have diuretic administration as a single does and monitor for symptomatic responsiveness. The patient may be given the secondary does if SA does not respond to 20 mg. it will be important to start furosemide 40 mfg daily.

Problem 2: Bradycardia along with fatigues to chronic kidney disease and sotalol accumulation. It is important to begin sotalol to atone the beta blocker in the renal elimination but keeping in view the SA'; kidneys dysfunction and signs of toxicity, a taper will occur naturally secondary to the renal clearance that is decreased. It will be important to assess magnesium level and replacement if hypomagnesaemia exists (Saczynski, Darling, Spencer, 2009).

Problem 3: chronic kidney disease based on the creatinine ...