PDA

View Full Version : CC: "Swollen feet and shortness of breath when walking more than half a block"



TomHsiung
Tue 14th June '16, 5:47pm
J.C., a 69-year-old white male with a diagnosis of right- and left-sided congestive heart failure, complains of swollen feet, shortness of breath when walking more than half a block, nonproductive cough that is worsen at night, and occasional leg cramps. He has gained 30 lb over the past 3 months and notes that all his clothes are too tight. He props himself up with three pillows when sleeping.

Try to make a therapeutic plan and monitor it.

TomHsiung
Tue 14th June '16, 6:04pm
1.IDENTIFY THE PROBLEMS

Step 1 - Obtain Patient Data

Subjective data:


Diagnosed with right- and left-sided congestive heart failure
Swollen feet
Shortness of breath when walking more than half a block
Nonproductive cough that is worsen at night
Occasional leg cramps
He has gained 30 lb over the past 3 months
He notes that all his clothes are too tight
He props himself up with three pillows when sleeping
The patient is sure that he take some medications for HF but can not remember what drugs he takes


Objective data:

Null


Step 2 - Group Related Data

Heart Failure Group
Subjective data: A diagnosis of right- and left-sided congestive heart failure, complains of swollen feet, shortness of breath when walking more than half a block, nonproductive cough that is worsen at night. He has gained 30 lb over the past 3 months and notes that all his clothes are too tight. He props himself up with three pillows when sleeping. The patient is sure that he take some medications for HF but can not remember what drugs he takes.
Objective data: Null

Leg Pain Group
Subjective data: Occasional leg cramps
Objective data: Null

Step 3 - Determine Each Problem

Right- and left-sided heart failure
Leg pain (need further investigation)‚Äč


Step 4 - Access Each Problem



Right- and left-sided heart failure: Chronic, not enough information[Seattle Heart Failure Model], symptomatic, treated, uncontrolled, stage C HF
Leg pain: Chronic, mild, symptomatic, untreated, uncontrolled, stage (?)

TomHsiung
Tue 14th June '16, 9:47pm
2.PRIORITIZE THE PROBLEMS

Step 1 - Identify the Active Problems

Right- and left-sided HF
Leg pain


Step 2 - Identify the Inactive Problems

Null


Step 3 - Rank the Problems
Active Problems That Need Immediate Therapeutic Intervention

Right- and left-sided HF


Active Problems Requiring Less Immediate Therapeutic Intervention


Leg pain


Inactive Problems of Historical Interest

Null


Of the patient's active problems, his HF is causing him the most immediate discomfort. The reason for leg pain needs further investigation but its urgency is less important than HF. Therefore, this patient's prioritized patient problem list is as follows:
1.Right- and left-sided HF
2.Leg pain

TomHsiung
Tue 14th June '16, 10:18pm
3.SELECT PATIENT-SPECIFIC DRUG AND NONDRUG INTERVENTIONS

Step 1 - Determine Short-Term and Long-Term Goals
Problem No.1: Right- and left-sided HF
Short-term goal: Controlling symptoms and decreasing morbidity.
Long-term goal: Preventing the onset of clinical symptoms or reducing symptoms, preventing or reducing hospitalizations, slowing progression of the disease, improving quality of life, and prolonging survival.

Problem No.2: Leg pain
Short-term goal: ?
Long-term goal: ?

Step 2 - Create a List of Options
Problem No.1: Right- and left-sided HF

Nonpharmacologic interventions

Dietary modifications sodium and fluid restriction
Smoking cessation
Stop alcohol consumption
Timely immunizations
Supervised regular physical activity


Diuretics

Systemic, loop diuretics (furosemide, bumetanide, torsemide)
Systemic, thiazide diuretics (hydrochlorothiazide, chlorthalidone, metolazone)


ACEIs

Systemic (captopril, enalapril, fosinopril, lisinopril, quinapril, ramipril, trandolapril)


Angiotensin receptor blockers

Systemic (candesartan, losartan, valsartan)


Vasodilators

Systemic (hydralazine + isosorbide dinitrate)


beta-Adrenergic antagonists

Systemic (bisoprolol, carvedilol, metoprolol)


Aldosterone antagonists

Systemic (spironolactone, eplerenone)


Inotropic

Systemic (digoxin)


Calcium channel blockers

Systemic, dihydropyridine (amlodipine, felodipine)


Antiplatelets

Systemic, NSAIDs (ASA)


Anticoagulants

Systemic (warfarin)



Problem No.2: Leg pain
?

Step 3 - Eliminate Options Based on Patient-Specific and External Factors
Problem No.1: Right- and left-sided HF
According to the current practice guideline, the recommended treatment for stage C HF consists of nonpharmacological interventions and pharmacological interventions. The recommended non pharmacological interventions include

patient education to facilitate HF self-care (I;B);
sodium restriction (IIa;C);
continuous positive airway pressure in HF patients who also have sleep apnea (IIa;B);
exercise training (or regular physical activity) (I;A);
and cardiac rehabilitation (IIa;B).
Besides the other nonpharmacological interventions including smoking cessation, stoping alcohol consumption, and timely immunization are also reasonable.
In addition, hypertension and lipid disorders should be controlled (I;A); other conditions that may lead to or contribute to HF, such as obesity, diabetes mellitus, tobacco use, and known cardiotoxic agents, should be controlled or avoided (I;C).


The pharmacological interventions consists of

Diuretics (I;C);
ACE inhibitors (I;A);
ARB when ACE inhibitors are intolerant (I;A);
ARB to replace ACI inhibitors as first-line therapy for patients with HFrEF (IIa;A);
ACE inhibitor + ARB maybe considered in persistently symptomatic patients with HFrEF who are already being treated with an ACE inhibitor and a beta blocker in whom an aldosterone antagonist is not indicated or tolerated (IIb;A)
Routine combined use of an ACE inhibitor, ARB, and aldosterone antagonist is harmful (III;C)
beta-Blocker (bisoprolol, carvedilol, sustained-release metoprolol succinate) (I;A);
Aldosterone receptor antagonists are recommended in patients with NYHA class II-IV HF and who have LVEF of 35% or less (I;A);
Aldosterone receptor antagonists are recommended in patients following an acute MI who have LVEF of 40% or less and who develop symptoms of HF, or who have a history of diabetes mellitus (I;B)
The combination of hydralazine and isosorbide dinitrate is recommended to reduce morbidity and mortality for patients self-described as African Americans with NYHA class III-IV HFrEF receiving optimal therapy with ACE inhibitors and beta blockers (I;A)
A combination of hydrazine and isosorbide dinitrate can be useful to reduce morbidity or mortality in patient with current or prior symptomatic HFrEF who cannot be given an ACE inhibitor or ARB (IIa;B)
Digoxin (IIa;B)
Anticoagulation: Patients with chronic HF with permanent/persistent/paroxysmal AF and an additional risk factor for cardioembolic stroke should receive chronic anticoagulant therapy (I;A)
Anticoagulation: Chronic anticoagulation is reasonable for patients with chronic HF who have permanent/persistent/paroxysmal AF but are without an additional risk factor for cardioembolic stroke (IIa;B)
Omega-3 polyunsaturated fatty acid (PUFA) (IIa;B)


According to the guideline above we eliminate the options marked in red


Nonpharmacologic interventions

Dietary modifications sodium and fluid restriction
Smoking cessation
Stop alcohol consumption
Timely immunizations
Supervised regular physical activity


Diuretics

Systemic, loop diuretics (furosemide, bumetanide, torsemide)
Systemic, thiazide diuretics (hydrochlorothiazide, chlorthalidone, metolazone)


ACEIs

Systemic (captopril, enalapril, fosinopril, lisinopril, quinapril, ramipril, trandolapril)


beta-Adrenergic antagonists

Systemic (bisoprolol, carvedilol, metoprolol)


Aldosterone antagonists (?)

Systemic (spironolactone, eplerenone)


Inotropic

Systemic (digoxin)




Step 4 - Select Appropriate Drug and Nondrug Interventions
Problem No.1: Right- and left-sided HF
1.Furosemide, 20 mg, tablet, PO, qd, indefinitely, rationale (the patent has symptoms of fluid retention, evidence supports furosemide's use in this condition to improve symptoms).
2.Ramipril, 2.5 mg, capsule, PO, q12h, indefinitely, rationale (evidence supports its use in this condition to improve morbidity and mortality)
3.Bisoprolol, 1.25 mg, tablet, PO, qd, indefinitely, rationale (evidence supports its use in this condition to improve morbidity and mortality)
4.Spironolactone (if the conditions required by guideline meet), 25 mg, tablet, PO, qd, indefinitely, rationale (evidence supports its use in this condition to improve morbidity and mortality)
5.Digoxin, 0.125 mg, tablet, PO, qd, indefinitely, rationale (evidence shows digoxin can reduce the hospitalization for HF)

Step 5 - Identify Alternative Interventions
Problem No.1: Right- and left-sided HF
1.If ramipril cannot be used we use a ARB (candesartan, losartan, valsartan)

TomHsiung
Fri 17th June '16, 11:04pm
Initial Treatment Regimen
Rx
Furosemide 20 mg PO qd
Ramipril 2.5 mg PO q12h
Bisoprolol 1.25 mg PO qd
Spironolactone 25 mg PO qd (?)
Digoxin 0.125 mg PO qd

Dietary modifications sodium and fluid restriction
Smoking cessation
Stop alcohol consumption
Timely immunizations
Supervised regular physical activity