Clinical Vignette

          Read the clinical vignette. Discuss the patient's general approach, including laboratory testing, inpatient management, and rationale discharge prescription, by answering the given questions. A 69-year-old man with a past medical history (PMH) of ischemic cardiomyopathy (EF 25%), CAD, HTN presents with a two-week history of dyspnea. ▪ Previously able to walk 3 km, currently cannot walk more than 3 m before developing dyspnea on exertion (DOE). Paroxysmal nocturnal dyspnea (PND) three times per night and four pillow orthopnea. Increasing lower extremity edema. ▪ Review of Systems (ROS): loss of energy, loss of appetite, weight gain. ▪ Past medical history (PMH): ischemic cardiomyopathy (EF 25%, based on echocardiogram 6 months prior), CAD (s/p MI with PCI in 2012), HTN. ▪ Home medications: ASA 81mg daily, Lisinopril 5mg daily, Lasix 40 mg daily. ▪ Allergies: no known drug allergies (NKDA). ▪ Review of Systems (ROS): denies Cerebral palsy (CP), denies dizziness, denies palpitations. ▪ VS: Temp 36.5, HR 90, BP 108/72, RR 20, SpaO2 91% on RA ▪ Pertinent physical exam: o General: appears uncomfortable, able to speak short sentences o HEENT: Jugular venous distension at 10 cm o CVS: left ventricular enlargement. o Chest: A decrease tactile fremitus indicates chronic obstructive pulmonary disease. o Abdomen: distended, (+) mild fluid wave, (+) hepatojugular reflux, o Extremities: 2+ pitting edema up to knees bilaterally, cool to touch, 2+ DP and PT pulses o Current presentation consistent with acute decompensated heart failure (ADHF) ▪ What labs and toxicology screening should be ordered to help evaluate further? ▪ How often should his electrolytes be monitored? ▪ At this point, what imaging should be obtained to further assist with management? Master of clinical Toxicology, Level 2, UQU, 2021 ▪ Should an echocardiogram be repeated? ▪ How should inpatient management begin (Drugs chart/ inpatient prescription)? ▪ Suggest which groups of drugs improve the mortality and morbidity in this patient management. ▪ Clarify how the patient’s volume status should be improved. ▪ What could be done next if the patient did not respond to the treatment given for patient’s volume status? ▪ Is Digoxin should be included in this patient management (justify). ▪ Should the patient’s management begin with a beta blocker at this time? ▪ Which beta blocker (if any) should be chosen? ▪ Which risk about blood pressure? ✓ The patient has been having an appropriate diuresis ✓ Clinically, patient reports improvement in shortness of breath and now able to walk without DOE ✓ Pulmonary embolism (PE): resolution of rales, peripheral edema ▪ Rationale the patient’s discharge prescription? ▪ Clear the rational and importance of the medicines in the discharge prescription.