Posted: June 9th, 2015

case study

A.J. is a 58 year-old man that presents to your clinic with a chief complaint of increasing shortness of breath and an 8 kg weight gain. Two weeks prior he noted the onset of dyspnea on exertion after one flight of stairs, orthopnea, and ankle edema. Since then he has noted PND and has been able to sleep only in a sitting position. A.J. notes a productive cough, nocturia, and, dependent edema.

PMH includes: Heartburn, OA managed with NSAIDS, depression, and HTN.

Physical Exam: dyspnea, cyanosis, and tachycardia. VS: B/P 160/100 mmHg, Pulse: 90 beats/minute, Respirations: 28 breaths/minute. His neck veins are distended, S₃ gallop is heard. PMI is at the sixth ICS_, 12 cm from the midsternal line. His liver is enlarged and tender to palpation, and a positive hepatojugular reflux is observed. He is noted to have 3+ pitting edema of the extremities and sacral edema.

Medication History: HCTZ 25 mg QD, Motrin 600 mg QID, ranitidine 150 mg QHS, Lexapro 20 mg QD. He has NKDA and no dietary restrictions.

Recent lab results: Hct-41.1%, WBC 5,300/mm^3, Na 132 mEq/L, K+ 3.2 mEq/L, CI 100 mEq/L, bicarbonate 30 mEq/L, Mg 1.5 mEq/L, FBS 100mg/dL, BUN 40 mg/dL, SrCr 0.8 mg/dL, Alk Phos 44U, AST 30 u/l, BNP 364 pcg/mL, TSH 2.0. The CXR shows bilateral pleural effusions and cardiomegaly.

1. What signs, symptoms, and laboratory abnormalities of Heart Failure (HF) does A.J. exhibit? Relate these clinical findings to the pathogenesis of the disease and to left-sided or right-sided HF.

2. Does A.J. have systolic or diastolic HF?

3. What stage of HF does A.J. exhibit according to the ACA/AHA criteria? How severe is A.J.’s disability according to the NYHA functional classification of HF?

4. What factors contributed to the cause of A.J.’s HF?

5. What are the basic mechanisms by which drugs can induce HF, and how can an understanding of these mechanisms be predictive of drugs to avoid in A.J.?

6. What are the therapeutic goals in treating A.J.?

7. You decide to begin a combination regimen of furosemide and an ACE Inhibitor for A.J. What route, dose, and dosing schedule of the medications should be used?

8. Looking at A.J.’s laboratory values, does he have any abnormal values? What is the significance of these abnormalities?

9. Would use of a potassium-sparing diuretic such as triamterene offer any advantages over a potassium supplement to prevent or treat hypokalemia? What diuretic should be used?

10. A.J. received a 1-g dose of magnesium sulfate and three 3-20-mEq doses of potassium chloride. Should he receive a prophylactic magnesium or potassium supplement? What is the best drug and appropriate route?

Case studies taken from:

Koda-Kimble, M., Young, L., Alldredge, B., Corelli, R., Guglielmo, B., Kradjan, W., & Williams, B. (2009). Applied therapeutics: The clinical use of drugs. (9^th ed.) Philadelphia, PA: Lippincott, Williams and Wilkins