NR603 Week 4 iHuman Cardiopulmonary Case Study Summary

Patient Information:

• Initials: C.B.
• Age: 70 years old
• Race: Caucasian
• Sex: Female
• Medical History: Hypertension, 26-year history of smoking (1 pack per day)

Chief Complaint:

• The patient presents with worsening shortness of breath (SOB) over several years, which is now progressively worsening, particularly with exertion. The patient also reports some swelling in her feet and ankles, along with fatigue.

Subjective Data:

• Shortness of Breath: Worse with exertion, improves with rest.
• Swelling: Reports bilateral lower extremity swelling (feet and ankles).
• Fatigue: Feels tired more often, impacting her daily activities.

Objective Data:

• Vital Signs: Not provided, but vital signs would be essential to complete the assessment.
• Cardiovascular Exam:
  • Pansystolic murmur noted on auscultation.
  • Bilateral 1+ pretibial edema observed.
• Respiratory Exam:
  • Lungs are clear to auscultation.
• Echocardiogram Results:
  • Mean gradient consistent with severe aortic stenosis.
  • Estimated valve area consistent with severe/critical aortic stenosis (0.65 cm²).

Assessment:

• Primary Diagnosis: Severe Aortic Stenosis (ICD-10: I35.0)
  • Rationale: The echocardiogram results, coupled with the patient’s clinical presentation of shortness of breath, fatigue, and edema, strongly indicate severe aortic stenosis. The pansystolic murmur on physical exam further supports this diagnosis.
• Secondary Diagnosis:
  • Hypertension (ICD-10: I10)
    • Uncontrolled hypertension, despite current treatment with amlodipine.
  • Chronic Tobacco Use (ICD-10: F17.210)
    • 26-year history of smoking contributes to cardiovascular risk.
  • Congestive Heart Failure, unspecified (ICD-10: I50.9)
    • The presence of edema, shortness of breath, and fatigue suggests early heart failure, possibly secondary to the severe aortic stenosis.

Diagnostic Testing:

• Echocardiogram:
  • Already performed; confirms severe aortic stenosis.
• Electrocardiogram (ECG):
  • To evaluate any underlying arrhythmias or ischemic changes due to severe aortic stenosis.
• Chest X-ray:
  • To assess for any signs of pulmonary congestion or cardiomegaly.
• Basic Metabolic Panel (BMP) and Complete Blood Count (CBC):
  • To check for electrolyte imbalances, renal function, and to evaluate for anemia.
• BNP (B-type Natriuretic Peptide):
  • To assess for heart failure and correlate with the severity of heart failure symptoms.

Plan:

1. Medications/Treatment:
   • Rosuvastatin 5mg daily: To manage hyperlipidemia as per guidelines, especially given the association between calcific aortic stenosis and lipid metabolism.
   • Ramipril 2.5mg daily: An ACE inhibitor to manage hypertension, and reduce afterload, which may benefit the patient’s overall cardiac function.
   • Spironolactone 12.5mg PO daily: An aldosterone antagonist for both blood pressure control and heart failure management, especially useful in reducing fluid retention.
2. Surgical Consultation:
   • Valve Replacement: The patient should be referred to a cardiothoracic surgeon to discuss the potential benefits and risks of valve replacement surgery, given the severity of her aortic stenosis.
3. Patient Education:
   • Diet: Emphasize the importance of a heart-healthy, low-sodium diet to manage both hypertension and heart failure symptoms.
   • Exercise: Encourage regular, low-impact exercise to improve cardiovascular health, while being mindful of the patient’s symptoms and limitations.
   • Daily Weight Monitoring: Educate the patient on the importance of monitoring daily weight to detect early signs of fluid retention. Advise reporting a weight gain of 3-5 pounds over 1-2 days, as this could indicate worsening heart failure.
   • Smoking Cessation: Strongly advise the patient to quit smoking and provide resources for smoking cessation programs.
4. Follow-Up:
   • Close Monitoring: Schedule follow-up visits to monitor the patient’s blood pressure, medication adherence, and any changes in symptoms. Adjust treatment as necessary based on clinical progress.

By addressing these aspects comprehensively, the management plan aims to stabilize the patient’s condition and improve her quality of life, while also preparing her for potential surgical intervention for the severe aortic stenosis.