All questions apply to this case study. Your responses should be brief and to the point. When asked to provide several answers, list them in order of priority or significance. Do not assume information that is not provided. Please print or write clearly. 

You are working in the internal medicine clinic of a large teaching hospital. Today your first patient is 70-year-old J.M., a man who has been coming to the clinic for several years for management of coronary artery disease (CAD) and hypertension (HTN). A cardiac catheterization done a year ago showed 50% stenosis of the circumflex coronary artery. He has had episodes of dizziness for the past 6 months and orthostatic hypotension, shoulder discomfort, and decreased exercise tolerance for the past 2 months. On his last clinic visit 3 weeks ago, a chest x-ray (CXR) showed cardiomegaly, and a 12-lead electrocardiogram (ECG) showed sinus tachycardia with left bundle branch block (LBBB). You review his morning blood work and initial assessment.

 

■ Chart View

Laboratory Testing Chemistry 

Sodium 142 mEq/L 

Chloride 95 mEq/L

Potassium 3.9 mEq/L 

Creatinine 0.8 mg/dL 

Glucose 82 mg/dL 

BUN 19 mg/dL

 

CBC 

WBC 5400/mm 3 

Hgb 13 g/dL 

Hct 41% 

Platelets 229,000/mm 3

 

Initial Assessment Complains of increased fatigue and shortness of breath, especially with activity, and “waking up gasping for breath” at night, for the past 2 days. 

 

Vital Signs 

Temperature 97.9° F (36.6° C) 

Blood pressure 142/83 mm Hg 

Heart rate 105 beats/min 

Respiratory rate 18 breaths/min

 

1. As you review these results, which ones are of possible concern, and why?

2. Knowing his history and seeing his condition this morning, what further questions are you going to ask J.M. and his daughter?

 CASE STUDY PROGRESS

J.M. tells you he becomes exhausted and has shortness of breath climbing the stairs to his bedroom and has to lie down and rest (“put my feet up”) at least an hour twice a day. He has been sleeping on two pillows for the past 2 weeks. He has not salted his food since the physician told him not to because of his high blood pressure, but he admits having had ham and a whole bag of salted peanuts 3 days ago. He denies having palpitations but has had a constant, irritating, nonproductive cough lately. 

3. You think it\\\'s likely that J.M. has heart failure (HF). From his history, what do you identify as probable causes for his HF؟

4. You are now ready to do your physical assessment. For each potential assessment finding for HF, indicate whether the finding indicates left-sided heart failure (L) or right-sided heart failure (R). 

1. Fatigue, weakness, especially with activity 

2. Jugular (neck) vein distention 

3. Dependent edema (legs and sacrum) 1 Cardiovascular 

4. Hacking cough, worse at night 

5. Enlarged liver and spleen

6. Exertional dyspnea 

7. Distended abdomen 

8. Weight gain 

9. S3/S4 gallop 

10. Crackles/wheezes in lungs

 

■ Chart View

Medication Orders

Enalapril (Vasotec) 10 mg PO twice a day 

Furosemide (Lasix) 20 mg PO every morning 

Carvedilol (Coreg) 6.25 mg PO twice a day 

Digoxin (Lanoxin) 0.5 mg PO now, then 0.125 mg PO daily

Potassium chloride 10 mEq tablet PO once a day

 

Case study progress

The physician confirms your suspicions and indicates that J.M. is experiencing symptoms of early left-sided heart failure. Medication orders are written. 

5. For each medication listed, identify its class, and describe its purpose for the treatment of HF. 

6. When you go to remove the medications from the automated dispensing machine, you see that carvedilol (Coreg CR) is stocked. Will you give it to J.M.? Explain.

 7. As you remove the digoxin tablet from the automated medication dispensing machine, you note that the dosage on the tablet label is 250 mcg. How many tablets would you give?

 8. Based on the new medication orders, which blood test or tests should be monitored carefully? Explain your answer

 9. When you give J.M. his medications, he looks at the potassium tablet, wrinkles his nose, and tells you he “hates those horse pills.” He tells you a friend of his said he could eat bananas instead. He says he would rather eat a banana every day than take one of those pills. How will you respond? 

CASE STUDY PROGRESS

This is J.M.\\\'s first episode of significant HF. Before he leaves the clinic, you want to teach him about lifestyle modifications he can make and monitoring techniques he can use to prevent or minimize future problems. 

10. List five suggestions you might make and the rationale for each.