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INTRODUCTION

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CASE LEARNING OBJECTIVES

  • Differentiate among the common underlying etiologies of heart failure (HF), including ischemic, nonischemic, and idiopathic causes.

  • Identify signs and symptoms of HF and classify a given patient by the New York Heart Association Functional Classification (NYHA FC) and American College of Cardiology/American Heart Association (AHA) HF Staging.

  • Develop a specific evidence-based pharmacologic treatment plan for a patient with acute or chronic HF based on disease severity and symptoms.

  • Properly educate a patient taking chronic HF medications.

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PATIENT PRESENTATION

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Chief Complaint

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"I was so short of breath this morning I couldn't get out of bed. My legs have also been quite swollen, especially by the end of the day."

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History of Present Illness

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DB is a 64-year-old Hispanic male who presents to the emergency department with a 3-day history of shortness of breath, lower extremity swelling, and an 18-lb (8-kg) weight gain. About 4 days ago, he ran out of medications and was unable to make it to the pharmacy to refill his medications. This morning, the shortness of breath persisted at rest to the point he could not get out of bed. This prompted him to come to the hospital. The patient also admits to waking up at night to catch his breath and needing at least three pillows to prop himself up while sleeping because he feels like he is drowning when laying flat. In the emergency room, he was placed on oxygen, given his home dose of amlodipine, given intravenous boluses of furosemide without much response, and then started on a furosemide intravenous infusion at 5 mg/h. After 3 hours, DB had no symptomatic relief and was transferred to the cardiac intensive care unit for further management.

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Past Medical History

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HTN × 20 years

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Bipolar disorder × 6 years

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Family History

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Father had type 2 diabetes, HTN, and died at age 84 from an unknown cause. Mother is alive at age 87 with HTN and gout.

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Social History

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Fluent in English and Spanish. Divorced and lives alone. He has a son who visits him about once a week for help around the house. Retired, used to work as a mechanic, now mainly sedentary. Eats mainly processed or premade foods.

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Tobacco/Alcohol/Substance Use

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Denies alcohol use; (−) tobacco or illicit drug use

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Allergies/Intolerances/Adverse Drug Events

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Benazepril (cough)

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Medications (Current)

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HCTZ 25 mg PO q am

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Amlodipine 10 mg PO q 24 h

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Lithium 300 mg PO q 8 h

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Review of Systems

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Well-appearing male unable to lie flat in bed. No complaints of ...

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