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Running Head: COMPREHENSIVE CLINICAL CASE STUDY
Comprehensive Clinical Case Study
Jessica L. Gutsjo
Wright State University-CoNH
Nur 7201 – 01
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COMPREHENSIVE CLINICAL CASE STUDY
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History and Physical
Source
Patient, reliable sources
Chief Complaint
Shortness of breath
History of Present Illness
KRJ is a 28-year-old female who presents to the emergency department for increased
shortness of breath. The patient states that approximately 10 days ago she “had a cold” and
reports to taking “over-the-counter sinus medicine, NyQuil.” Patient states that “it seemed like
the cold got worse and then went into my chest.” Patient states that she was taking “a lot of
NyQuil and other over-the-counter medications to try and help.” She noted a fair amount of
coughing, without production of sputum, and “some fullness in my chest”. She denies orthopnea
or lower extremity edema. Patient states that she did feel warm but she never took her
temperature. Overall, the patient reports to “feeling terrible and very tired,” and subsequently,
she went to her primary care physician (PCP). Her PCP obtained a chest x-ray (CXR) and sent
her directly to the hospital. PCP felt she was in heart failure (HF). The official reading on her
chest x-ray reports “extensive pneumonia.” The patient is diaphoretic and feels hot today. Her
white count on admission was 14,000.
She does have a history of hypertension. She has not taken her medication for several
months; she said she did not have time to go back to her doctor to have them refilled and to be
re-evaluated. She denies any exertional chest pain. Up until this week she had been participating
in physical activities twice a week without any difficulty.
Medical History
COMPREHENSIVE CLINICAL CASE STUDY
Polycystic ovaries
Allergic rhinitis
Unspecified essential hypertension
Surgical History
Non-contributory
Family History
Problem
Cancer – brain
Diabetes
Heart Disease
Hypertension
Relation
Maternal Grandmother
Paternal Grandfather
Paternal Grandfather
Paternal Grandmother
Social History
Single
No children
Years of Education: 15
Occupation: Law Student
Never smoker or smokeless tobacco
Uses alcohol socially: Approximately 1-2 drinks per weekend
Denies illegal drug use
Sexually active with male partner
Exercises 2-3 times per week
Allergies
No known allergies
Medications (Prior to diagnostic studies)
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Levonorgest-Eth Estrad 91-day
(SEASONALE) 0.15-0.03 mg tablets
Guaifenesin-codeine
(CHERATUSSIN AC) 100-10 mg/5
mL syrup
Lisinopril 10 mg tablets
Cetirizine HCl (ZYRTEC)
Take 1 tablet by mouth daily
Take 5 mL’s by mouth every 4 to 6 hours as
needed
Take 1 tablet by mouth daily (has not taken in
a number of months)
Take 1 tablet by mouth daily
Review of Systems
General:
Reports fatigue. Denies unexplained weight loss, loss of appetite, fever, or
chills.
Neurological:
Denies memory changes, dizziness, headache, numbness and tingling.
HEENT:
Denies facial swelling, vision changes, changes in hearing, nasal congestion,
or sore throat.
Neck:
Denies neck pain, stiff neck, and swollen glands.
Respiratory:
Complains of chest tightness, shortness of breath, dyspnea on exertion,
wheezing, and coughing. Denies sputum production. Patient is unsure if she
has sleep apnea but admits to snoring.
CV:
Denies irregular heartbeat and chest pain. No evidence of edema.
GI:
Denies nausea, vomiting, swallowing difficulty, diarrhea, and constipation.
GU:
Denies painful urination, frequency, urgency, hesitancy, and irregular periods.
M/S:
Denies muscle, joint pain, or decreased range of motion.
Skin:
Denies rash and skin color changes or any new lesions.
Psychosocial:
Complaints of anxiety and stress due to PCP sending the patient to the ED
emergently. Denies depression. No suicidal or homicidal ideations.
Physical Exam
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Vitals:
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BP 163/83, Pulse 106, Temp 98.1°F, Resp 24, Wt 258 lb (117.028 kg), SpO2
95%
General:
Awake, alert, aware of and responsive to stimuli. Perceptions and thought
process are logical and coherent. Dress is appropriate for setting, age, gender,
and social group. Hygiene is clean and well-groomed. Affect is appropriate to
place and condition. Anxious mentation. No acute distress.
Neurological:
Alert, oriented to person, place, time, and situation. Pupils are equal, round,
reactive to light and accommodation (PERRLA). Cranial nerves II-XII intact.
No focal deficits noted.
HEENT:
Cranium is normocephalic. No lumps, depressions, or abnormal protrusions.
Facial symmetry with no swelling or involuntary movements. Head is
centered in midline with symmetrical accessory neck muscles. Intact skin with
no redness, swelling, discharge, or lesions. Scleras are white. Smooth
movement with no limitation, no tenderness, and no crepitation. No tenderness
to frontal and maxillary sinuses. Mobility and facial symmetry. Tongue is pink
with no white patches or lesions. Buccal mucosa is pink with no nodules or
lesions. Tonsils 2+, visible.
Neck:
Smooth movement with no limitation, no tenderness, and no crepitation. Skin
has no lesions. No Jugular Venous Distention. Carotids 2+ and equal
bilaterally with no bruit. Nodes are movable, discrete, soft and non-tender. No
palpable lobes, nodules or lumps. Bilateral equal strength in sternomastoid and
trapezius muscles. No lymphadenopathy or goiter.
Respiratory:
Bibasilar crackles and rhonchi, no respiratory distress. No use of accessory
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COMPREHENSIVE CLINICAL CASE STUDY
muscles, symmetrical chest expansion with no pain upon inspiration, no
stridor. Respirations are even and unlabored. Capillary refill is normal (<1
second). No cyanosis noted.
CV:
Regular rate and rhythm, S1 and S2 present with no murmurs, gallops, clicks
or rubs; distant heart tones. Pulses are 2+ bilateral upper extremities and 1+
bilateral lower extremities.
Abdomen:
Skin is smooth and even with homogenous color. Umbilicus is midline and
inverted with no sign of hernia. Contour is rounded but obese. Normoactive
bowel sounds on all four quadrants; abdomen is soft, non-tender, no
organomegaly, no masses, no tenderness.
M/S:
Range of motion normal bilateral upper and lower extremities, no
erythematous or swollen joints. No tenderness, pain or crepitation upon joint
movement. Strength 5/5 bilaterally upper and lower extremities. No scoliosis,
lordosis or kyphosis. Gait is smooth and effortless.
Skin:
Warm and dry, no lesions. Nail beds smooth surface, not brittle or splitting.
Laboratory Findings (During in-patient)
Table. 1. Basic Metabolic Panel and Complete Blood Count
Basic
Results
Reference
Complete
Metabolic
Ranges
Blood Count
Panel (BMP)
(CBC)
Sodium
139 mEq/L
135-145
WBC
mEq/L
Potassium
4.2 mEq/L
3.6-5.1
RBC
mEq/L
Chloride
108 mEq/L
101-111
Hemoglobin
mEq/L
Carbon
23 mEq/L
24-36 mEq/L Hematocrit
dioxide
Results
Reference
Ranges
14.0
3.6-10.5
THOU/mcL
THOU/mcL
3.94 MIL/mcL 3.8-5.2
MIL/mcL
9.4 g/dL
12.0-15.2
g/dL
29 %
36-46 %
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Glucose
BUN
Creatinine
104 mg/dL
13 mg/dL
0.9 mg/dL
Ionized
Calcium
Anion Gap
4.7 mg/dL
74-99 mg/dL MCV
8-26 mg/dL
MCH
0.5-1.2 mg/dL MCHC
RDW
4.6-5.4 mg/dL Platelet
14
6-18
ABS
Neutrophil
ABS Lymphs
ABS Monos
RBC
Morphology
Table. 2. Other Laboratory Findings (4/16/13)
Results
Reference
Ranges
Protime
9.9 seconds
9.0-11.4
seconds
INR
0.9
0.8-1.2
PTT
30.1 seconds 23.0-32.5
seconds
75 fL
24 pg
32 g/dL
17.8 %
498
THOU/mcL
11.62
THOU/mcL
1.68
THOU/mcL
0.70
THOU/mcL
2+
Polychromasia
2+
Microcytosis
82-97 fL
27-33 pg
32-36 g/dL
<15.3 %
140-375
THOU/mcL
1.80-7.70
THOU/mcL
1.00-4.00
THOU/mcL
0.20-0.90
THOU/mcL
Results
Reference
Ranges
0-47 pg/mL
BNP
340 pg/mL
CPK
Troponin
108 IU/L
0.09 ng/mL
TSH
2.2 mIU/L
0-200 IU/L
0.00-0.05
ng/mL
0.5-5.0
mIU/L
Diagnostic Findings
Two diagnostic studies were performed in the ED, a 12-lead electrocardiogram (ECG)
and a CXR PA and lateral. The 12-lead ECG (Appendix A) revealed: Sinus rhythm with a Left
Bundle Branch Block (LBBB), a heart rate of 97 bpm, PR of 152mS, and a QTc of 554mS. The
CXR PA and lateral impression states “extensive pneumonia suggested or possible pulmonary
edema and cardiomegaly also noted”. The patient was admitted to the telemetry unit where an
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echocardiogram (ECHO) was performed and two sets of blood cultures were obtained. The
ECHO revealed the following:
Overall left ventricular ejection fraction is estimated to be 20-25%.
The left ventricular function is severely decreased.
The left ventricle is mildly dilated.
There is severe global hypokinesis of the left ventricle.
The pulmonary artery is not well visualized, but is probably normal size.
The estimated right ventricular systolic pressure is consistent with mild pulmonary
hypertension.
Mild tricuspid regurgitation is present.
Differential Diagnosis
In general there are a number of differential diagnoses in individuals presenting with
signs and symptoms of HF. For instance, myocardial ischemia; pulmonary disease such as,
pneumonia, asthma, chronic obstructive pulmonary disease (COPD), pulmonary embolus (PE),
and primary pulmonary hypertension; sleep disturbances; obesity; deconditioning from bedrest
or sedentary lifestyle; malnutrition; anemia; hepatic failure; chronic kidney disease (CKD);
hypoalbuminemia; venous stasis; depression; anxiety; hyperventilation; and hyper- or hypothyroidism (Lindenfeld et al., 2010, p. 482). However, the role of the provider is to distinguish
the correct diagnosis or the most likely.
The most likely diagnosis for this patient is systolic HF due to her estimated EF of 2025% revealed with the ECHO; CXR revealing possible pulmonary edema and cardiomegaly;
BNP of 340 pg/mL; and symptoms of shortness of breath, cough, dyspnea on exertion, and chest
tightness. Systolic HF is defined as a syndrome caused by cardiac dysfunction due to any
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condition causing an alteration in left ventricular function (Harrison & Longo, 2013). There are a
multiple rationales for the alteration in left ventricular function as evidenced by a depressed EF,
an EF of <40%, as seen in this patient. For example, coronary artery disease (CAD) causing
myocardial infarction or myocardial ischemia; chronic pressure overload due to hypertension or
obstructive valvular disease; chronic volume overload from regurgitant valvular disease,
intracardiac shunting, or extracardiac shunting; nonischemic dilated cardiomyopathy attributed to
familial or genetic disorders; toxic/drug-induced damage due to metabolic disorders or virus; and
Chagas’ disease causing disorders of rate and rhythm, or chronic brady- or tachy- arrhythmias
(Harrison & Longo, 2013, p. 1901). The rationales for systolic HF previously listed would
require further investigation to properly manage the cause of the HF. Classic symptoms of HF
include fatigue and shortness of breath (Harrison & Longo, 2013), both of which this patient
presents with. The fatigue seen with HF is attributed to the low cardiac output due to the poor
pumping abilities of the heart, evidenced by her EF of 20-25%. This patient also presents with
dyspnea on exertion and is also a common symptom of an individual with HF in the early stages
(Harrison & Longo, 2013). Another common finding in HF is pulmonary congestion as
evidenced by this patient’s CXR revealing pulmonary infiltrates (Harrison & Longo, 2013). This
patient presents with a LBBB seen on her ECG and is attributed to a possible diagnosis of
coronary heart disease and is frequently demonstrated in individuals with an impaired left
ventricular function, as seen in this patient (Harrison & Longo, 2013). Individuals with
hypertensive heart disease also present with a LBBB on ECG, and is likely in this patient due to
the her history of noncompliance with anti-hypertensive medications (Harrison & Longo, 2013).
Viral cardiomyopathy is also a common cause to the development of a LBBB on ECG (Harrison
& Longo, 2013).
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The next likely diagnosis for this patient is community-acquired pneumonia (CAP). CAP
is defined as an infection of the alveolus of the lung (Tintinalli, Cline, & American College of
Emergency Physicians (ACEP), 2012). Signs and symptoms of CAP include fever, cough with
sputum production, fatigue, dyspnea, pleuritic chest pain, and evidence of an infection
(Tintinalli, Cline, & ACEP, 2012). This particular patient does not present with a fever or
pleuritic chest pain. However, this patient does present with cough but without sputum, fatigue,
dyspnea, and evidence of a possible infection as evidenced by her white blood cell (WBC) count
of 14.0 THOU/mcL. The possibility of CAP in conjunction with systolic HF is a possible
diagnosis. Therefore, the patient could receive an antibiotic; such as, Doxycycline to treat
pneumonia until blood culture results return and sputum cultures are sent to rule-out or diagnosis
pneumonia in conjunction with systolic HF.
Other possible diagnoses in this particular patient to rule-out include myocardial ischemia
and pulmonary embolus (PE). Anteroseptal, anterolateral, and inferior myocardial infarctions
(MI) commonly present with a LBBB, as seen in this patient (Harrison & Longo, 2013).
However, the patient does not demonstrate other findings of an MI upon her ECG; such as STsegment elevation or depression, or T-wave inversions. Therefore, the patient should have serial
ECG’s, CK-MB’s, and Troponin’s to diagnose or rule-out an MI. Due to the patients
presentation of shortness of breath, the diagnosis of a PE requires further investigation. PE is
defined as the presence of a blood clot in the pulmonary vasculature preventing adequate
ventilation to perfusion ratio causing individuals to present with shortness of breath and
hypoxemia. A common finding with PE is sinus tachycardia, as evidenced in this patient; and an
S-wave in lead I, a Q-wave in lead III, and a T-wave inversion in lead III, but is not
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demonstrated in this patient (Harrison & Longo, 2013). A D-dimer and spiral CT scan could be
performed on this patient to rule-out or diagnosis a PE.
Diagnostic Studies
In the hospital setting, signs and symptoms presented by the patient is the primary
method of diagnosing HF in individuals who are suspected to have HF (Jessup et al., 2009). The
provider should perform a thorough history and physical, with focus on systemic perfusion,
volume status, precipitating factors, comorbidities, and if the heart failure is associated with a
preserved EF (Jessup et al., 2009, p. 1997). The presence of elevated cardiac filling pressures and
fluid overload can be diagnosed through the assessment finding of an elevated jugular venous
pressure, rales, ascites, S3 gallop, positive hepatojugular reflux (HJR), and edema (Lindenfeld et
al., 2010). Cardiac enlargement can be diagnosed through auscultating a laterally displaced
apical impulse, a prominent apical impulse, or valvular dysfunction as evidenced by a murmur
(Lindenfeld et al., 2010). Reduced cardiac output can be determined through the presence of a
narrow pulse pressure, tachycardia with pulsus alternans, and cool extremities (Lindenfeld et al.,
2010). And an arrhythmia can be assessed through palpitating an irregular pulse indicative of
atrial fibrillation or ectopy (Lindenfeld et al., 2010). The assessment finding of dyspnea on
exertion has a 100% sensitivity and 17% specificity for the diagnosis of HF (Dokainish et al.,
2004).
Also in the hospital setting, a number of laboratory studies should be performed to
diagnosis or rule-out HF. A B-type natriuretic peptide (BNP) or N-terminal pro-B-type
natriuretic peptide (NT-proBNP) is other method for diagnosing HF in individuals who present
with dyspnea and signs and symptoms compatible with HF; however, the diagnosis of HF should
not be made from this single laboratory study (Jessup et al., 2009 & Lindenfeld et al., 2010). A
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BNP and NT-proBNP level is useful in the diagnosis of HF because BNP is released by the
ventricular myocardium due to an increase in pressure and volume (Gomella, Haist, &
University of Kentucky (UK), 2007). A BNP >300 pg/mL with a reduced EF is 88% sensitive
and is 90% specific for the diagnosis of HF, whereas the presence of NT-proBNP is 68%
sensitive and 56% specific for the diagnosis of HF (Dokainish et al., 2004). An additional
laboratory study is obtaining serial, every six hours for a total of three, cardiac troponin (CKMB) levels and ECG’s to rule-out or diagnosis an acute coronary syndrome (ACS) (Jessup et al.,
2009). Other laboratory studies to obtain include serum electrolytes, fasting lipid/liver panel,
complete blood count, thyroid function, uric acid, and a urinalysis (Lindenfeld et al., 2010).
Essential diagnostic studies include CXR, ECG, and ECHO (Jessup et al., 2009). A PA
and lateral CXR is recommended to examine heart size, the presence of fluid overload and
pulmonary disease, and if present, if implanted cardiac devices are implanted correctly
(Lindenfeld et al., 2010). An ECG is recommended to examine cardiac conduction and rhythm,
electrical dyssynchrony as evidenced by a widened QRS complex or bundle branch block, left
ventricular hypertrophy, and myocardial infarction or ischemia (Lindenfeld et al., 2010). When
cardiomegaly, pulmonary edema, or both are present on the CXR, the findings are 71% sensitive
and 92% specific for the diagnosis of HF (Dosh, 2004). An ECHO is recommended to examine
the cardiac structure and function; particularly patients who have a history of CAD; valvular
heart disease; first-degree relative with a cardiomyopathy; atrial flutter or fibrillation; ECG
revealing LBBB, left ventricular hypertrophy, Q-waves, ventricular arrhythmia; or cardiomegaly
(Lindenfeld et al., 2010, p. 481). An ECG revealing Q-waves or a LBBB is 94% sensitive and
61% specific for diagnosing the presence of HF (Dosh, 2004). However, an ECHO is 96%
COMPREHENSIVE CLINICAL CASE STUDY
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sensitive and 80% specific for diagnosing HF in the setting of a BNP >300 pg/mL with a reduced
EF (Dokainish et al., 2004).
Coronary angiography is another essential diagnostic tool in the setting of heart failure,
particularly in the newly diagnosed patient, such as this patient (Jessup et al., 2009). CAD is a
common comorbidity leading to the development of heart failure and can be examined through
coronary angiography and revascularization can be established during this procedure via stent
placement.
Plan
Medications. In individuals who are diagnosed with systolic HF, an EF less than 45%, he
or she is recommended by the American College of Cardiology Foundation (ACCF) (2009),
American Heart Association (AHA) (2009), and the Heart Failure Society of America (HFSA)
(2010) to take a number of essential medications to improve the patients’ symptoms, quality of
life, and longevity while reducing the progression of disease. Prior to this hospitalization, this
particular patient had a history significant for unspecified essential hypertension but was noncompliant with medications.
The most fundamental of medications in systolic HF is the utilization of beta-blockers
and angiotensin-converting enzyme inhibitors (ACEi) or angiotensin receptor blockers (ARBs).
Beta-blockers with ACEi’s or ARBs are recommended to improve mortality while slowing or
stopping the progression of HF by inhibiting the renin-angiotensin-aldosterone system (RAAS)
(Lindenfeld et al., 2010). For individuals who are asymptomatic or symptomatic with an EF less
than or equal to 40%, he or she is recommended to receive an ACEi (Lindenfeld et al., 2010).
The dose of ACEi should be the same dose utilized in clinical trials or as tolerated; for instance,
Captopril 50 mg TID, Enalapril 10 mg BID, Lisinopril 20 mg once daily, Quinapril 80 mg once
COMPREHENSIVE CLINICAL CASE STUDY
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daily, Ramipril 10 mg once daily, or Trandolapril 4 mg once daily (Lindenfeld et al., 2010).
ACEi’s are contraindicated in individuals with severe renal insufficiency, not evident in this
patient; however, serum creatinine and potassium levels require close monitoring to ensure
maintenance of superior renal function and normal potassium values. If the patient presents with
renal insufficiency or hyperkalemia with the utilization of an ACEi or ARB, the use of
hydralazine in conjunction with an oral nitrate is recommended in placer of the ACEi or ARB
(Lindenfeld et al., 2010). During this time, the use of beta-blockers would be instituted and
would also be titrated to a dose used in clinical trials; such as, Bisoprolol 10 mg once daily,
Carvedilol 25 mg BID, Carvedilol extended-release 80 mg once daily, or Metoprolol succinate
extended-release 200 mg once daily (Lindenfeld et al., 2010). Beta-blockers are also
recommended for individuals with an EF less than or equal to 40% due to multiple large scale
trials providing strong evidence in the reduction or mortality and morbidity (Lindenfeld et al.,
2010). The provider prescribing the beta-blocker should be cautious of bradycardia, hypotension,
and is not recommended in individuals with asthma due to the risk of bronchospams (Lindenfeld
et al., 2010). A side effect of ACEi’s is a dry cough, and should not be confused with worsening
pulmonary edema, and if present, the utilization of an ARB in place of the ACEi is
recommended (Lindenfeld et al., 2010). In addition, the combination of ACEi and ARB is not
recommended (Lindenfeld et al., 2010). Examples of ARB’s include Losartan 150 mg once daily
and Valsartan 160 mg BID (Lindenfeld et al., 2010). However, an individual may be intolerant to
ARB’s as well and the use of hydralazine in conjunction with an oral nitrate is recommended in
place of the ARB (Lindenfeld et al., 2010). Individuals with HF and a reduced EF who continue
to be symptomatic could also receive the combination therapy of hydralazine in conjunction with
an oral nitrate in addition to the beta-blocker and ACEi or ARB (Lindenfeld et al., 2010).
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To obtain euvolemia in individuals who present with orthopnea, edema, shortness of
breath, jugular vein distention, peripheral edema, pulsatile hepatomegaly, or rales loop-diuretic
therapy is recommended (Lindenfeld et al., 2010). Loop-diuretics are preferred in comparison to
thiazide diuretics due to the greater excretion of filtered sodium with loop-diuretics and the onset
of action is within minutes via the intravenous route with the loop-diuretics (Lindenfeld et al.,
2010). Examples of loop-diuretics are Bumetanide, Furosemide, and Torsemide. In addition to
monitoring the patient’s volume status, the provider needs to closely monitor serum electrolyes,
particularly potassium, and creatinine as this class of medication can cause hypokalemia with an
increase in creatinine.
The next class of medications to initiate on this patient is an aldosterone antagonist.
Aldosterone antagonist is recommended in individuals with a reduced EF of less than 35% and
individuals with New York Heart Association (NYHA) class IV symptoms of HF; marked
limitation of physical activity with fatigue, palpitations, or dyspnea with less than ordinary
activity (Lindenfeld et al., 2010). Aldosterone antagonist are not recommended in individuals
with hyperkalemia, a potassium level greater than 5.0 mmol/L, or increased creatinine of greater
than 2.5 mg/dL due to likelihood of worsening hyperkalemia and creatinine (Lindenfeld et al.,
2010). Subsequently, serum creatinine and potassium levels require close monitoring when this
class of medication is utilized due to its’ mechanism of action and potassium supplements are
contraindicated. Examples of aldosterone antagonists at their target doses include Spironolactone
25 mg once daily or Eplereone 50 mg once daily (Lindenfeld et al., 2010).
Metolazone (Zaroxolyn) may also be indicated in patients with persistent fluid retention
despite maximal loop-diuretic therapy. However, the use of Metolazone is not for daily or
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continuous use; this medication should be instituted for a short period of time on an as needed
based due to risk of electrolyte abnormalities and volume depletion.
Digoxin is recommended to improve symptoms in individuals with an EF less than or
equal to 40% and continue to have signs and symptoms of HF while receiving ACEi and betablockers (Lindenfeld et al., 2010). Digoxin is recommended due to its’ positive inotropic abilities
of increasing myocardial contractility, a quality lacking in those with systolic HF. The
recommended dose of Digoxin is 0.125mg daily (Lindenfeld et al., 2010).
Anticoagulation and antiplatelet medications are also recommended in patients with HF
due to the patients increased risk for developing an arterial or venous thrombosis attributed to the
reduced ventricular function. The reduced ventricular function promotes pooling of blood in
ventricle causing a thrombus is likely develop (Lindenfeld et al., 2010). Anticoagulation therapy
includes warfarin (Coumadin) and antiplatelet therapy includes aspirin, cilostazol, clopidogrel,
prasugrel, and ticagrelor (Lexi-Comp, Inc., 2013).
To summarize, as the ACNP, prescriptions would be as the following:
1. Restart home dose of 10 mg Lisinopril PO once daily and increase to 20 mg PO once
daily as tolerated in two weeks after starting Lisinopril
2. Start 3.125 mg Carvedilol PO BID and increase to 25 mg BID as tolerated
a. Start at 3.125 mg for two weeks, increase to 6.25 mg for two weeks, 12.5 for
two weeks, and 25 for two weeks (Lindenfeld et al., 2010)
b. Assess the patient at two-week intervals prior to increasing dose
3. While in the hospital, start on 20 mg Lasix IV BID and increase to 40 mg BID if
indicated, patient is not diuresing as anticipated and/or persistent pulmonary edema is
evident
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a. At home, discharge with Lasix PO BID at dose where maximal benefit was
noted
b. Monitor BMP daily in hospital and once a week at discharge
i. May need to start Potassium supplements, particularly if used as
monotherapy but no supplementation if Spironolactone (Aldactone) is
prescribed as well
4. Spironolactone (Aldactone). Would not start right now, would see how patient does
with Lasix. If patient necessitates further diuresing due to pulmonary edema then 12.5
mg Spironolactone (Aldactone) PO once daily to a maximum of 25 mg once daily
(Lindenfeld et al., 2010).
5. Metolazone (Zaroxolyn). Would not start right now. Would only institute if patient
was Lasix and Spironolactone (Aldactone) in conjunction were not effective. 5 mg
Metolazone (Zaroxolyn) PO Monday, Wednesday, Friday
a. If started on Metolazone (Zaroxolyn), monitor BMP weekly
b. May need Potassium supplements
6. Do not start combination of hydralazine and oral nitrate, wait to see the patients
response to medications listed 1-4.
7. Would not start Digoxin at this time. Institute if continues to have symptoms while
receiving maximal therapy of ACEi and beta-blockers. Starting dose of 0.125mg
daily
8. As mentioned previously, the administration of Doxycycline may be prescribed due
to the patient’s possible diagnosis of community-acquired pneumonia
a. 100 mg BID PO for 7-10 days (Lexi-Comp, Inc., 2013)
COMPREHENSIVE CLINICAL CASE STUDY
(J. Gutsjo) 18
b. Will not affect QTc interval
An Acute Care Nurse Practitioner (ACNP) in the state of Ohio has the Authority to
Prescribe (ATP) all of the medications named above with the exception of anticoagulants,
warfarin (Coumadin). Warfarin (Coumadin) can be prescribed by the ACNP once the physician
initiates or the physician has been consulted prior to the prescription. The Standard Care
Agreement (SCA) between the ACNP and collaborating physician must clearly indicate either
physician initiate or consult for this class of medications (Ohio Board of Nursing, 2011).
Treatments. The medications named above would be considered part of the treatment
plan. However, the patient may be a candidate for a bi-ventricular (“bi-v”) implantable
cardioverter defibrillator (ICD). Prior to making judgment for the definitive placement of a bi-v
ICD, the patient requires being on optimal medical therapy (Epstein et al., 2008). The patient is
in the beginning stages of medical therapy management and requires a minimum of ninety days
of optimal therapy before diagnostic studies; such as an ECHO, can be performed to re-evaluate
her cardiac function, specifically her EF. Cardiac resynchronization therapy (CRT) with or
without an ICD is indicated in individuals with NYHA class III or IV HF symptoms, have an EF
less than or equal to 35%, are in sinus rhythm, and have a QRS duration greater than or equal to
0.12 seconds or 120mS; all of which the patient currently presents with (Epstein et al., 2008).
Interventions. In addition to the medication regimen listed above, the patient would
benefit from having a coronary angiogram and the utilization of a life vest upon discharge.
Coronary angiography is recommended in patients with congestive HF due to a reduced EF with
angina, in the presence of wall motion abnormalities, or when revascularization is considered in
individuals with reversible myocardial ischemia (Scanlon, 1999, p. 2355). Coronary angiography
is also recommended in patients with an unexplainable cause for systolic dysfunction despite
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(J. Gutsjo) 19
noninvasive testing, as seen in this patient (Scanlon, 1999, p. 2355). The life vest is a noninvasive wearable defibrillator and protecst the patient from sudden cardiac death due to a lifethreatening arrhythmia. The life vest is able to monitor and record the patient’s arrhythmia and
delivers a shock to the heart when deemed necessary. The life vest is indicated in individuals
who have an EF less than or equal to 35%, as seen in this patient; after recent myocardial
infarction; during the ninety day waiting period for ICD implantation, high probability for this
patient; waiting for cardiac transplant; and individuals with NYHA class IV HF, as seen in this
patient as well (ZOLL Medical Corporation, 2012).
Health promotion activities. There are a number of health promotion activities to be
recommended in individuals with systolic HF. A restriction of sodium intake to two to three
grams daily is recommended; however, a restriction of less than two grams daily is
recommended in individuals with moderate to severe HF, as seen in this patient (Lindenfeld et
al., 2010). Excessive sodium intake leads to a hypervolemic state causing the patient to have an
exacerbation in their HF and commonly requiring medication enhancements and hospitalizations.
In addition, fluid restrictions are not indicated in this patient due to her serum sodium level of
139 mEq/L; however, if her serum sodium level was less than 130 mEq/L a less than two liter
per day fluid restriction is recommended (Lindenfeld et al., 2010). Also, individuals who are
restricting their sodium intake and who are receiving high-doses of diuretics may require the
same fluid restriction, less than two liters per day, if he or she continues to display fluid retention
(Lindenfeld et al., 2010). This particular patient is obese and requires weight management
strategies; however, weight loss in a healthy manner is always recommended. The patient may
require prealbumin and nitrogen balance laboratory work-up to ensure she is not becoming
malnourished (Lindenfeld et al., 2010). The utilization of a multivitamin supplement is
COMPREHENSIVE CLINICAL CASE STUDY
(J. Gutsjo) 20
recommended as well (Lindenfeld et al., 2010). The patient denies a history of sleep apnea but
does admit to snoring; the patient should be referred to a sleep physician to evaluate for the
presence of sleep apnea where the prescription for proper treatment via continuous positive
airway pressure (CPAP) mask can be received (Lindenfeld et al., 2010). The utilization of CPAP
during sleep as shown to improve EF and symptoms but not survival rates (Lindenfeld et al.,
2010). Additionally, patients should be evaluated for depression and treated with selective
serotonin reuptake inhibitors (SSRI’s) instead of tricyclic antidepressants due to their potential to
potentiate ventricular arrhythmias (Lindenfeld et al., 2010). This patient denies nicotine
dependence but admits to social alcohol use; the patient would be advised to limit alcohol intake
to one or less standard drink per day due to alcohol changing myocardial metabolism (Lindenfeld
et al., 2010). This patient would also be advised to become up-to-date with her immunizations,
including influenza and pneumococcal vaccination (Lindenfeld et al., 2010). Prior to returning to
exercise, the patient would be advised to go through exercise testing to ensure she does not
develop arrhythmias due to cardiac exertion (Lindenfeld et al., 2010).
Follow-up
This particular patient or any patient with systolic HF requires follow-up within one week
post-discharge with multiple visits there after depending upon signs and symptoms evident at the
follow-up appointment. However, at every follow-up appointment he or she requires a thorough
assessment of symptoms, efficacy of medication regimen, functional ability including level of
activity, body weight, and prognosis (Lindenfeld et al., 2010). In addition, the provider would
want to re-evaluate, provide continued education, and encourage compliance in regards to
sodium restriction, medication regimen, and alcohol limitations (Lindenfeld et al., 2010). The
provider would evaluate the patient’s vital signs to ensure an adequate blood pressure and heart
COMPREHENSIVE CLINICAL CASE STUDY
(J. Gutsjo) 21
rate and change medications as needed in attempts to reach clinical trial doses. Frequent
monitoring of BMP levels would also be necessary to ensure adequate electrolyte values;
particularly potassium, and to ensure adequate renal function via serum creatinine values. The
provider would want to thoroughly assess symptoms, particularly any symptoms of pre-syncope,
syncope, palpitations, shortness of breath, fatigue, angina, and edema. Also, the patient was
discharged home with a life vest and the provider would want to ensure proper function and if
the ICD has delivered a shock. Lastly, the provider would want to order an ECHO at ninety days
of optimal therapy to re-evaluate the patient’s cardiac function and consult an electrophysiology
(EP) physician if necessary.
COMPREHENSIVE CLINICAL CASE STUDY
(J. Gutsjo) 22
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COMPREHENSIVE CLINICAL CASE STUDY
Appendix A
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