Pathophysiology week 08

Case # 822999: Shortness of Breath (SOB)

The health record # 822999 has been reviewed with research of the following diseases: congestive heart failure, pleural effusion, and pneumonia. Pertinent information in the health record will be disclosed such as diagnosis, history, physical findings, lab/x-ray results, treatments and condition of patient at discharge. Research on each disease will include pathology, symptoms/signs, diagnosis, and treatments /alternative treatments. The appropriateness of treatment for this patient will be summarized at the end. (NIH.gov, 2012)(medcinenet, 2012)
Accordingly to the history and physical, the 73 year-old female presented to the ER with complaint of SOB X 3-4 days, not sleeping well, and was observed to have increase pedal edema (swelling of ankles and feet). She denied having a cough or fever. Her past history revealed atrial fibrillation, severe regurgitation from tricuspid and mitral valve dysfunction. No history noted of heart valve repair or replacement. She is allergic to Sulfa. (NIH.gov, 2012)(medcinenet, 2012)
Medications taken prior to her admission includes the following: 1. Capoten 25 mg po (oral) tid (three times per day). Capoten is an angiotensin-converting enzyme (ACE) inhibitor and acts as a vasodilator, decreasing blood pressure, improve blood flow, and decrease the workload of the heart. 2. Furosemide 40 mg po qd (every day). Furosemide is a diurectic and blocks the absorption of sodium, chloride, and water from the filter fluid of the kidneys tubules, causing an increase output of urine. Furosemide is perscribed for heart failure and for decreasing fluid in the lungs. Diuretics can causeake the body lose potassium and magnesium; thereby, supplements may be needed. 3. Digoxin 0.125 mg po qod (every other day). Digoxin increases the strength and vigor of the heart contractions by inhibiting an enzyme ATPase that controls calcium, potassium, and sodium into the heart. It also slows electrical conduction between the atria and ventricles of the heart; useful in treating abnormal rapid atrial rhythms such as atrial fibrillation. 4. Nortriptyline HCL 10 mg po qhs (every hour of sleep). Nortriptyline is an antidepressant. This medication increases epinephrine and serotonin , two neurotransmittors in the brain. When there is a balance between epinephrine and serotonin, it elevates mood. 5. Tylenol 325 mg po tabs prn (when needed) for pain. Tylenol is an acetaminophen/ analgesic. 6. Klor 10 mg qd. Potassium supplement for possible hypokalemia (serum <3.5) from diuretic use. 7. Milk of Magnesia (MOM) 30 cc po qd prn. MOM is reduces stomach acids and increases water in the intestines, use for constipation or indigestion. (NIH.gov, 2012)(medcinenet, 2012)
Physical examination: HEENT (head, eyes, ears,nose throat): Difficult fundoscopic exam. Neck: Supple with positive venous distention. Technique for evaluating venous return to the right cardiac atrium. Positive venous return signifies presence of volume overload secondary to heart failure. CNS: Rate 104, irregular with gallop. Crackles (rale/ abnormal sound heard during inspiration with stethoscope) in left lower lobe. Right is dull. Abdomen: benign. Genitalia: Normal except for red sacral area. No obvious breakdown. Extremities: 3+ pitting edema to knees. Neurological: Appropriate. Alert.Assessment: Congestive heart failure, left pleural effusion, pneumonia. Plan: Admit; diurese; IV antibiotics; blood cultures and sputum if possible; O2; bedrest. Admitting and principle diagnosis: Congestive heart failure, left pleural effusion, pneumonia. (NIH.gov, 2012)(medcinenet, 2012)
Chest x-ray: Indication: Left pleural effusion, congestive heart failure, pneumonia. Findings: PA (posteroanterior projection) and lateral chest compared with chest x-ray taken 6 days earlier. Slight improvement in the left lower lung field infiltrate. Small bilateral pleural fluid collections persist. Stable cardiac and mediastinal silhouettes. Conclusion: Slight interval improvement of appearance of the chest. (NIH.gov, 2012)(medcinenet, 2012)
Primary diagnosis per Physician orders: Congestive heart ,severe end stage ischemic cardiomyopathy. (NIH.gov, 2012)(medcinenet, 2012)
End stage heart failure occurs when treatment no longer work. At this point, the physician, patient and family have to discuss the options of palliative or comfort care for patient. (NIH.gov, 2012)(medcinenet, 2012)
Medications on admission include the following: Capoten 25mg po tid; Furosemide 40 mg po qd; Nortripyline HCL 10 mg po qd; Digoxin 0.125 mg po qod. No potassium supplement ordered. Diet: Low sodium, low cholesteral, and no dairy products due to lactose intolerance. Physical therapy (PT): Evaluate and gait training ambulation with appropriate assistance device. Occupational therapy (OT) was ordered for strengthening, endurance building and ADL (activities of daily life) training. No blood test, sputum test ordered or diagnostic test ordered. Standing orders for that particular facility section/department covered bodily dysfunction occurrence and treatments such as for bowl management (MOM/Fleets enema), diarrheal ( kaopectate), UTI (urinary tract infections/ obtaining urinalysis), dyspnea (oxygen 2liters/min prn nasal cannula), GI distress ( stock antacid), cough (stock Guaifenesin), skin breakdown treatment and vaccinations. There was no documentation noted for medications given, nor nursing treatments charted if done, nor if any labs where done and if done, no results reported. No IV infusions recorded nor was noted. PT and OT notations verified her need in receiving therapy. (NIH.gov, 2012)(medcinenet, 2012)
Heart failure, which is also referred to as congestive heart failure, occurs most commonly in the elderly. This is the chronic condition in which the heart is unable to pump out all the blood that it receives. The decreased pumping action causes congestion. Congestion means a fluid buildup. The left sided heart failure, which is also known as pulmonary edema, causes an accumulation of fluid in the lungs. This occurs, because the left side of the heart is not efficiently pumping blood to and from the lungs. The right sided heart failure causes fluid buildup beginning with the feet and legs. The swelling can also affect the liver, gastrointestinal tract, or arms. This occurs because the right side of the heart is not efficiently pumping blood to and from the rest of the body, with the exception of the lungs. (NIH.gov, 2012)(medcinenet, 2012)
Common symptoms for heart failure are: cough, fatigue, weakness, faintness, loss of appetite, need to urinate at night, pulse that feels fast or irregular or a sensation of feeling the heart beat, swollen liver or abdomen,edema in feet and ankles, waking up from sleep after a couple of hours due to shortness of breath, and weight gain. (NIH.gov, 2012)(medcinenet, 2012) (nursingcenter, 2012)
In addition to symptoms of CHF, a physical examine done by physician will also obtain valuable information. Signs of heart failure may include the following: tachypnea (fast) or dyspnea (difficult breathing), irregular or fast heartrate. Leg swelling (edema), neck viens that stick out (are distended), sounds from fluid buildup in your lungs, heard through a stethoscope, swelling of the liver or abdomen.
The best test to diagnosis CHF is the echocardiogram. This test also can reveal the cause, and monitor the heart failure. Other tests include cardiac stress test, heart catheterization, MRI, nuclear heart scan. Lab tests reveal electrolyte balance or unbalance, evaluate function of kidneys (BUN, creatinine clearance, urinalysis), anemia, test for brain natriuretic peptide (BNP) (NIH.gov, 2012)(medcinenet, 2012)(nursingcenter, 2012)
Treatment for heart failure involves medications, close monitoring by physician and patient self care which includes patient monitoring their heart-rate, pulse, blood pressure, weight, and lifestyle changes such low-salt diet, quitting smoking, getting enough rest and exercise and taking in medication as prescribed. Doctors can sometimes treat heart failure by treating the underlying cause. For example, repairing a heart valve or controlling a fast heart rhythm may reverse heart failure. For most people, the treatment of heart failure involves a balance of the right medications, and in some cases devices that help the heart beat and contract properly. (NIH.gov, 2012)(medcinenet, 2012) ) (nursingcenter, 2012)
Medications are given according to symptoms the heart patient may have. ACE inhibitors are a type of vasodilator, a drug that widens the blood vessels to lower the blood pressure (Capoten). A drug like Digoxin increases the strength of the heart muscle contractions and slows the heart-rate. Beta blockers slows your heart rate, and reduces blood pressure, but also limits and reverses some damage to the heart while actually improving heart function (Zebeta or Coreg). Diuretics decrease fluid in your lungs so you can breathe easier and keeps fluid volume from collecting in the body. Potassium and magnesium may have to be supplemented due to excess loss. Other medications may be used such as nitrates for chest pain, statin to lower cholesterol and blood thinners to prevent blood clots. Oxygen may need to be used with severe heart failure. (NIH.gov, 2012)(medcinenet, 2012) (nursingcenter, 2012)
With end stage heart failure, treatments no longer work. Heart failure is usually a chronic illness, which may get worse over time. Some people develop severe heart failure, in which medicines, other treatments, and surgeries no longer help. Hospice care or palliative care allows family and friends which the aid of nurses, social workers, and trained volunteers to care for and comfort the patient at home, or in a hospice residence. It also provides emotional, social and spiritual support for people who are ill and those closest to them. The program is available anywhere in such places such as nursing homes, and assistance living centers. (NIH.gov, 2012)(medcinenet, 2012) (nursingcenter, 2012)
A plural effusion is a buildup of fluid between the layers of tissue that line the lungs and chest cavity. The body produces pleural fluid in small amounts to lubricate the surfaces of the pleura, the thin tissue that lines the chest cavity and surrounds the lungs. There are two types of effusions. Transudative pleural effusions are caused by fluid leaking into the pleural space. Congestive heart failure is the most common cause. Exudative effusion are caused by blockage from inflammation, lung injury, and drug reactions. Sharp chest pain with cough or deep breath, cough, fever, hiccups, rapid breathing, shortness of breath are all symptoms found in pleural effusion. Treatment aims to remove the fluid, prevent fluid buildup, and treating cause. For congested heart failure, pleural effusion are treated with diuretics. In cases of infections, pleural effusion is treated by antibiotics. (NIH.gov, 2012)(medcinenet, 2012)(Mayoclinic, 2012)
Pulmonary edema is a condition caused by excess fluid in the lungs. In most cases, heart problems cause pulmonary edema. But fluid can accumulate for other reasons, including pneumonia, exposure to certain toxins and medications, and exercising or living at high elevations.
Pneumonia is an inflammation of the lung, usually caused by an infection. Three common causes are bacteria, viruses and fungi. People most at risk are older than 65 or younger than 2 years of age, or already have health problems. If you have pneumonia, you may have difficulty breathing and have a cough and a fever. Preventing pneumonia is always better than treating it. There is a vaccine for pneumococcal pneumonia. The goals of treatment are to cure the infection and prevent complications. If pneumonia is severe, IV antibiotics are recommended and oxygen therapy. Adults with heart failure get the pneumococcal polysaccharide vaccine (PPSV). (NIH.gov, 2012)(medcinenet, 2012)
From the data in her chart, the patient appears to be in declining health. The physician did provide an order for an evaluation for physical therapy (PT) and a telephone order to the nurse for occupational therapy (OT). Both PT and OT were relevant to the patient's endurance and activities of daily life (ADL). Statements made in the integrated process notes by both PT and OT provide valuable information on the process vs. limitations and recommendations that involves the patient's independence and safety. One can conclude that the patient suffering from shortness of breath (SOB), which is one symptom that can result from congestive heart failure and/or pneumonia, could benefit from therapeutic O2 if needed. Patient's medications such as Capoten (decreases blood pressure), Furosemide (a diuretic), and Digoxin (treats heart failure) all were necessary medication treatment for congestive heart failure. (NIH.gov, 2012)(medcinenet, 2012)
Admitting summary documentation in the history and physical and again verified in the chest x-ray report. The physician orders and progress notes on 6/13/xx stated the primary diagnosis as congestive heart failure and severe end stage ischemic cardiomyopathy (disease of heart muscles) with no mention of left pleural effusion and pneumonia. Additional to the diagnosis, the history and physical documents admitting physician advised that patient's admitting plan included intravenous antibiotics, blood culture, and sputum culture. Neither intravenous infusion, nor intravenous antibiotics, nor blood culture, and nor sputum culture appeared as an order in the physician’s order. There also was no other documentation of an IV infusion, nor an intravenous antibiotic given, nor blood culture nor sputum culture obtained. The data was missing. Also according to the transfer documentation, a CBC and an UA were done. If it was done, the data was missing. (NIH.gov, 2012)(medcinenet, 2012)
The physician orders a diet with “low sodium, low cholesterol. Lactose intolerance. No diary products; however, on the transfer form, dietary is checked unrestricted. This is consequential, because patient was CHF along with 3+ edema in the legs and some fluid in her left lung. She does not need more sodium and she does not tolerate lactose. (NIH.gov, 2012)(medcinenet, 2012)
My final conclusion of the treatment of care for patient in chart # 822999 with a diagnosis of CHF, severe end stage cardiomyopathy was directly given for assessing and maintaining the future needs for the patient. Code level was documented for no CPR (cardiopulmonary resuscitation). Medication ordered per physician was appropriate for diagnosis. X-ray report showed slight improvement of appearance of chest, when compared to last chest x-ray done six days prior. Question I had was the left lower lung filtrate with pleural effusion diagnosed as pneumonia prior to latest admission? OT and PT was appropriately given and suggestions revealing for on going care when transfer to new facility. Chart is diffidently lacking data or notation why no antibiotics were implemented or lease the reason not to. Perhaps some notation on how her other important organs where functioning such as her kidneys would be helpful in assessing care. How about her electrolyte balance, there is no data showing electrolytes are with in normal limits. Potassium taken prior to admission was not reordered. Some of the nurses vital signs charted such as pulse 24, respiration 64, B/P 112/62 or pulse 20, inspirations 72, B/P 108/56 while patient sits eating dinner or wants to sit in the recliner must be a charting error. I do believe that patient's cognitive impairment is secondary to her end-stage cardiac failure. The charting notations and medication Nortriptyline HCL responded appropriately to her cognitive impairment. Finally, addressing the end stage of cardiac failure besides “no CPR” would have been a nice alternative seeing in a physician's notation, which there were none or at lease addressed with a discharge summary prior to transfer how the patient and the her family are dealing with a prognosis or future plans/possible consultants in dealing with prognosis. Final adequate assessment in care delivered to this patient was hindered due to missing data. (NIH.gov, 2012)(medcinenet, 2012)

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