Clinical Scenario Prompt:

The setting is the Emergency Room

Pearl Rosetta is a 75yo female with a complaint of shortness of breath

History Elements:

• Constant since last night
• Woke her from sleep
• Worse with lying down
• Improves with sitting up
• Associated with non-radiating chest pressure
• Has experienced this in the past
• Usually requires two-pillows to sleep
• Admitted to hospital for “something similar” 3 weeks ago. The doctor discharged her on “a bigger dose of my medication, but at my follow up appointment 3 days ago, he decreased it again.”
• Adherent to medication
• No dietary indiscretion. Low salt diet. Limits fluids.
• No lower extremity swelling
• No prolonged travel (airplanes/car rides)
• No syncope
• No foreign travel
• No fevers, chills, sputum production, anorexia
• PMH: CAD, Paroxysmal Atrial Fibrillation (PAF), HTN, HLD, Chronic Combined Systolic and Diastolic Heart Failure, Anemia of Chronic Disease, DM2, CKD IV
• PSH: CABG with bioprosthetic mitral valve replacement (2017), right-sided pacemaker (2011), stent to mid RCA (2012), left sided carotid endarterectomy (2005)
• Meds: Aspirin 81mg PO qd, Carvedilol 12.5mg PO bid, Hydralazine 50mg PO tid, Insulin Glargine 18u qhs, Insulin Lispro 6u ac, Rosuvastatin 40mg PO qd, Warfarin 4mg PO qd Sat, Sun, Tues, Thurs, Warfarin 6mg PO qd Mon, Wed, Fri, Amlodiopine 10mg PO qd, Torsemide 40mg bid
• Allergies: NKDA, no environmental, no food allergies
• Family History: Father deceased at 44yo 2’ to CAD, MI. Mother deceased at ?yo 2’ to Lung CA.
• Social: + smoking history former 40 pack-year smoker, 1 pack per day x 40y. No EtOH, illicit drugs.
• ROS + for weakness, dyspnea, SOB, nonproductive cough, chest pressure. Otherwise negative.

Physical Exam:

• Vital Signs – P70, BP168/60, RR20, T36.5C, SpO293%RA
• Gen – A/O x 3. Appears upset, anxious. Mild distress.
• Neck – Scar on Left Neck s/p CEA. Trachea midline. No masses, lesions, scars. Supple. Nontender to palpation. FROM. No palpable lymphadenopathy.
• Chest – Symmetrical. No deformities. No paradoxical respirations or accessory muscle use. Respirations unlabored. Lat to AP diameter 2:1. Nontender to palpation.
• Lungs – Resonant to percussion throughout. Bibasilar crackles. No wheezing, rhonchi.
• CV – S1 and S2 normal. RRR. No m/g/r.
• Abdomen – non-distended, BS+, soft, nontender, no masses, lesions, no bruits
• Peripheral Vascular – extremities symmetric in color, temperature. Pulses 2+ throughout. No clubbing, cyanosis, edema. No stasis changes, ulcerations

Differential Diagnosis

• CHF Exacerbation – PMH of Chronic HF, + SOB, + Worse with lying flat, + Two-pillow orthopnea, + Recent hospitalization for CHF exacerbation and recent decrease in diuretic, + Bibasilar crackles, + elevated BNP, + CXR with findings classic for pulmonary edema
• Pulmonary Embolism – PMH of PAF, + SOB, + non-radiating chest pressure
• Acute Coronary Syndrome – PMH of CAD, HTN, HLD, other sig. cardiac history, + SOB, + non-radiating chest pressure, FHx of father deceased at 44yo 2/2 CAD/MI
• Valvular Heart Disease (Like Aortic Stenosis) – PMH of valvular disease and other sig. cardiac history, + SOB, + Bibasilar crackles
• COPD Exacerbation – Ex 40 pack-year smoker, + SOB, +non-productive cough
• Pneumonia – Ex 40 pack-year smoker, + SOB

Labs/Tests

• CBC – Hemoglobin/Hematocrit – 10.6/ 32.0 (normal for patient with anemia of chronic disease)
• BMP – Normal
• INR – 2.0 (adequately anticoagulated on Warfarin)
• Troponin I: Normal
• BNP: 679ng/mL (High)
• D-Dimer: Normal
• EKG: Atrial-paced rhythm (normal because she has an Atrial pacemaker). Otherwise normal.
• CXR: Heart mildly enlarged in size. Mild pulmonary vascular congestion. Cephalization of vessels noted. Kerley B lines present.

Treatment

• “LMNOP”

• IV Lasix
• Position: Sit patient up, dangle legs over side of bed to help decrease preload
• Consider:
  • Morphine (decreases afterload, venodilator)
  • Nitrates (venodilator)
  • Oxygen (especially since O2Sat was 93% on RA)

• Continuous monitoring of O2 sat, v/s, cardiac monitoring
• If admitted:
  • Daily weights
  • Strict I/Os

Patient Counseling

• Daily weights
• Na+ and fluid restriction
• Invite questions and use teach back to make sure that the patient has understood the important points