CVD Case Study
CVD Case Study
Case Overview
The patient is a 60-year-old woman who has been working as a baker. Her primary complaints include shortness of breath as well as non-productive cough that has lasted two months. Further, she experiences fatigue that constricts her daily activities while she manifests dyspnea when in a recumbent position. Her medical history examination reveals coronary artery disease and hypertension. The undertaken physical examination revealed the absence of acute distress, with 100 pulse rate and a B.P reading of 160/100. The patient’s lower lobes revealed crackles and distant air sounds. Distant S2 and S1 are revealed by cardiac examination alongside a perceived S3 over the apex.
Chief Complaint
The patient chief complaints include the shortness of breath that she experiences, the two-month non-productive cough and the attendant activity limitation.
Differential Diagnoses
a. Left-sided heart failure is the first diagnosis. In this condition, the fluids starts to back up the lung region since the heart is not able to accommodate the increased volume. This causes a pressure in the lungs making the patient to breathe easier at specific positions (Gauthier, Ray & Wenzel, 2015: Redfield, 2016). Sleeping and sitting enable the patient to breathe with comfort. The condition is caused by a coronary artery disease and chronic high blood pressure. These risk factors if not controlled may result in myocardial ischemia as well as decreased contractility of the heart.
b. Chronic obstructive pulmonary disease (COPD) is the second differential diagnosis. This is an insidious disorder that readily affects the older populations and with the patient’s symptoms, she is likely to have the condition (Pavord et al., 2018). However, the COPD is common to patients with a history of tobacco smoking. Besides, it is important to assess the exercise capacity of the patient as this affects the progression of COPD.
c. Pneumonia is also a differential diagnosis that relates to the complications of the patient. The disorder is associated with cough as well as fever and dyspnea all of which are evident in the patient. This is a complication of the chest in which coarse or fine crackles may be heard during auscultation of the affected lobe (Gauthier, Ray & Wenzel, 2015). Besides, the condition is linked to increase in fremitus and percussion done over the affected areas may appear dull which can make the patient feel afebrile. Pneumonia is also linked to shortness of breath especially based on fluid build-up in the lungs.
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Treatment Plan
Tests- The first treatment plan for the patient will include investigations such asNatriuretic peptides level, echocardiography, as well as chest x-ray and electrocardiogram. All these tests will play an important role not only in diagnosing the specific cardiac condition, but also rule out some of the differentials.
Medications: One of the most important medications that the patient will be given includes the administration of theCarvedilol 25 twice daily. The drug will be used to improve the ejection fraction of the patient’s left ventricle side. Moreover, a Furosemide 40 mg twice daily dose will also be prescribed (Redfield, 2016). This will be used to control the status of the fluid that is causing pain to the patient. Lastly, the patient will be given Enalapril 10 mg twice daily so as to cause neurohormonal modification and vasodilation.
Health education: Advise on moderate and regular exercise based on tolerance (Barnes, 2015). Further, the necessary lifestyle modifications that she has to make will also be critical here. Lastly, the importance of adhering to the given pharmacological intervention as well as reporting adverse effects will be emphasized.
Review: The patient should report for review and adjustments of medication after one month (Pavord et al., 2018). However, in case of complications before the review date, the patient need to seek further medication support in a health facility.
CVD Case Study References
Gauthier, M., Ray, A., & Wenzel, S. E. (2015). Evolving concepts of asthma. American journal of respiratory and critical care medicine, 192(6), 660-668.
Pavord, I. D., Beasley, R., Agusti, A., Anderson, G. P., Bel, E., Brusselle, G., … & Frey, U. (2018). After asthma: redefining airways diseases. The Lancet, 391(10118), 350-400. DOI: 10.1016/S0140-6736(17)30879-6.
Redfield, M. M. (2016). Heart failure with preserved ejection fraction. New England Journal of Medicine, 375(19), 1868-1877.
