I will copy and past two of my collegue’s discussion and upload the other two making it a total of four. all I need is for you to respond to their discussions separately with atleast I reference each
1) Discussion By Josephine :
A sixty-year-old baker presents to your clinic, complaining of increasing shortness of breath and nonproductive cough over the last month. She feels like she can’t do as much activity as she used to do without becoming tired. She even has to sleep upright in her recliner at night to be able to breathe comfortably. She denies any chest pain, nausea, or sweating. Her past medical history is significant for high blood pressure and coronary artery disease. She had a hysterectomy in her 40s for heavy vaginal bleeding. She is married and is retiring from the local bakery soon. She denies any tobacco, alcohol, or drug use. Her mother died of a stroke, and her father died from prostate cancer. She denies any recent upper respiratory illness, and she has had no other symptoms. On examination, she is in no acute distress. Her blood pressure is 160/100, and her pulse is 100. She is afebrile, and her respiratory rate is 16. With auscultation, she has distant air sounds and she has late inspiratory crackles in both lower lobes. On cardiac examination, the S1 and S2 are distant and an S3 is heard over the apex.
What is the chief complaint?
Chief Complaint: Shortness of breath and non-productive cough for one month. She also has complaints of feeling tired with activity and orthopnea.
Based on the subjective and objective information provided what are your 3 top differential diagnosis listing the presumptive final diagnosis first?
Three differential diagnoses for this patient are congestive heart failure, chronic obstructive pulmonary disease, and pneumonia.
Congestive heart failure (CHF) – Clinical manifestations of CHF can include dyspnea (including orthopnea), exercise intolerance, and fatigue. To assess cardiac function a chest radiograph and electrocardiogram are ordered to look for pulmonary edema or pulmonary effusions, or ECG abnormalities. Laboratory testing includes serum electrolytes, CBC, renal function, thyroid function tests, serum albumin, liver function tests, and brain natriuretic peptide (BNP). Findings suggestive of CHF include worsening renal function (decreased GFR), hyponatremia, hypoalbuminemia, abnormal liver tests, and elevated BNP. (Colucci and Dunlay, 2017) Risk factors for CHF include coronary heart disease, hypertension, obesity, smoking, diabetes, and valvular heart disease. (Vasan and Wilson, 2018) An S3 heart sound on exam can be a sign of left or right ventricle volume overload as in CHF. (Family Practice Notebook, 2019)
Chronic obstructive pulmonary disease (COPD) – Clinical manifestations of COPD are dyspnea, chronic cough, sputum production, and exertional dyspnea. The third ranked cause of death in the United States, COPD is a preventable disease as cigarette smoking is the most important risk factor for this disorder. (Han, Dransfield, and Martinez, 2018)
Pneumonia – Clinical features of pneumonia are cough, dyspnea, sputum production, fever, and pleuritic chest pain. Physical exam findings may include tachypnea, tachycardia, and crackles on auscultation of the lungs. Lab findings often reveal leukocytosis. (Bartlett, 2019)
What treatment plan would you consider utilizing current evidence-based practice guidelines?
Treatment for heart failure will depend on severity. Heart Failure due to left ventricular dysfunction is classified based on left ventricular ejection fraction and is either heart failure with reduced ejection fraction (HFrEF) or heart failure with preserved ejection fraction (HFpEF). Additional testing, such as echocardiogram, will be needed to assess ejection fraction. One goal of treatment in HFrEF is hypertension control, to improve cardiac function by decreasing left ventricular afterload. Recommended medicines for HTN in patients with CHF are beta blockers, ACE inhibitors, and ARBs. For this patient serum lipid levels should be obtained, and treatment initiated per findings as hyperlipidemia contributes to both hypertension and coronary artery disease. Lifestyle modifications that the patient must be educated about include sodium restriction (3g/day), fluid restriction (1.5 to 2L/day), and weight management. Diuretics may be used for fluid overload. According to Colucci (2018) “prolongation of patient survival has been documented with beta blockers, ACE inhibitors, ARNI, hydralazine plus nitrate, and MRA’s.”
References
Bartlett, J.G. (2019). Diagnostic approach to community acquired pneumonia in adults.
UpToDate. Retrieved from https://www.uptodate.com/contents/diagnostic-appro… adults?search=pneumonia&source=search_result&selectedTitle=3~150&usage_type=default&display_rank=3
Colucci, W.S. (2018). Overview of the therapy of heart failure with reduced ejection fraction.
UpToDate. Retrieved from https://www.uptodate.com/contents/overview-of-the-
therapy-of-heart-failure-with-reduced-ejection-
fraction?search=congestive%20heart%20failure%20treatment&source=search_result&se
lectedTitle=1~150&usage_type=default&display_rank
Family Practice Notebook. (2019). S3 heart sound. Retrieved from
https://fpnotebook.com/CV/Exam/S3HrtSnd.htm
Han, M.K., Dransfield, M.T., & Martinez, F.J. (2018). Chronic obstructive pulmonary disease:
Definition, clinical manifestations, diagnosis, and staging. UpToDate. Retrieved from
https://www.uptodate.com/contents/chronic-obstructive-pulmonary-disease-definition-
clinical-manifestations-diagnosis-and-
staging?search=COPD%20clinical%20manifestations&source=search_result&selectedTit
e=1~150&usage_type=default&display_rank=
Vasan, R.S. & Wilson, P.W. (2018). Epidemiology and causes of heart failure. UpToDate.
Retrieved from https://www.uptodate.com/contents/epidemiology-and-causes-of-heart-failure?search=causes%20of%20CHF&source=search_result&selectedTitle=1~150&use_type=default&di

2) Discussion By Sandra :

What is the chief complaint? She is complaining of increasing shortness of breath and nonproductive cough over the last month. She feels like she can’t do as much activity as she used to do without becoming tired. She even has to sleep upright in her recliner at night to be able to breathe comfortably.

2. Based on the subjective and objective information provided what are your 3 top differential diagnosis listing the presumptive final diagnosis first?
Acute Congestive Heart Failure. I50.9
Pulmonary Hypertension I27.0
Pulmonary Fibrosis J84.112
3.What treatment plan would you consider utilizing current evidence based practice guidelines?
Recognizing and diagnosis the cardiac cause is the key to the diagnosis of HF. Typically there diagnoses are a myocardial abnormality causing the dysfunction being systolic, diastolic or combined ventricular dysfunction. The can be other cardiac abnormalities of the valves, pericardium, endocardium, heart rhythm and conduction which can lead to HF, typically there are more than one of these illness present. Diagnosis the cause cardiac problem is crucial for being able to treat the HF. Conditions may require surgical intervention if a valvular issue or specific medications based on the type of HF.
The key to treatment is to determine or definition of heart failure with preserved (HFpEF), mid‐range (HFmrEF) and reduced ejection fraction (HFrEF).Patients without detectable LV myocardial disease may have other cardiovascular causes for HF (e.g. pulmonary hypertension, valvular heart disease, etc.). Patients with non‐cardiovascular pathologies (e.g. anaemia, pulmonary, renal or hepatic disease) may have symptoms similar or identical to those of HF and each may complicate or exacerbate the HF syndrome(Wiley 2016).

The initial diagnosis of HF may be obtained thru the plasma concentration of natriuretic peptides (NPs) at the non‐acute setting when an echocardiography is not immediately available in an outpatient clinic setting. When the NPs are increased this helps diagnosis the HF. Once those patient are identified the need further cardiac investigation; patients with values below the cut‐point for the exclusion of important cardiac dysfunction, these patients will not need echocardiography.

When the NP concentrations are normal HF is unlikely. “The upper limit of normal in the non‐acute setting for B‐type natriuretic peptide (BNP) is 35 pg/mL and for N‐terminal pro‐BNP (NT‐proBNP) it is 125 pg/mL; in the acute setting, higher values should be used [BNP < 100 pg/mL, NT‐proBNP < 300 pg/mL and mid‐regional pro A‐type natriuretic peptide (MR‐proANP) < 120 pmol/L]. Diagnostic values apply similarly to HFrEF and HFpEF; on average, values are lower for HFpEF than for HFrEF( Wiley 2016).”

When the electrocardiogram (ECG) is shown to be abnormal then the likelihood of the diagnosis of HF, but there is no specific type of HF able to be diagnosed. The most accurate was of diagnosis is echocardiography. This allows visualization of the chamber volumes, the systolic/diastolic ventricular function, thickness of the cardiac wall, the function of the valves and if there is pulmonary hypertension(Wiley 2016).

If the patient is complaining of symptoms for the first time or this is the initial presentation of HF, non‐urgently in their PCP office or in a hospital outpatient clinic the diagnosis of HF should first be evaluated based on the patient’s prior clinical history of uncontrolled hypertension or CAD that have needed the use of diuretics for treatment. The patient may present with orthopnoea, and on physical examination may have bilateral oedema, increased jugular venous pressure, displaced apical beat on ECG. If none of these symptoms are present a plasma NPs should be measured, and if a provided service, to identify those who need echocardiography (an echocardiogram is indicated if the NP level is elevated(Wiley 2016).

Treatment will be to control the hypertension. Diuretics, ACEIs, angiotensin receptor blockers (ARBs), beta‐blockers all have been successful in treating HTN especially in older adults.

Smoking Cessation is also key to treatment, even tho our patient is a non-smoker. Alcohol consumption is not recommended as toxic cardiomyopathy can occur.

A lipid panel is check and a statin started if indicated. Studies have shown that a statin can reduce the occurrence of a cardiovascular event or death and can delay or even prevent HF (Wiley2016).

Reference:

2016 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure. Ponikowski, Piotri. Voors, Adriaan A., Anker, Stefan D., Bueno, Hector., Cleland, John G.F., 2016, May 20. Retrieved from:https://onlinelibrary.wiley.com/doi/full/10.1002/ejhf.592

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