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

  1. #1
    PharmD Year 1 TomHsiung's Avatar
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    Default CC: "Swollen feet and shortness of breath when walking more than half a block"

    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.
    B.S. Pharm, West China School of Pharmacy, Class of 2007, Health System Pharmacist, RPh. Hematology, Infectious Disease.

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    PharmD Year 1 TomHsiung's Avatar
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    Default Re: CC: "Swollen feet and shortness of breath when walking more than half a block"

    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: O
    ccasional leg cramps
    Objective data: Null

    Step 3 - Determine Each Problem
    • Right- and left-sided heart failure
    • Leg pain (need further investigation)


    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 (?)
    Last edited by TomHsiung; Tue 14th June '16 at 11:38pm.
    B.S. Pharm, West China School of Pharmacy, Class of 2007, Health System Pharmacist, RPh. Hematology, Infectious Disease.

  3. #3
    PharmD Year 1 TomHsiung's Avatar
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    Default Re: CC: "Swollen feet and shortness of breath when walking more than half a block"

    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
    B.S. Pharm, West China School of Pharmacy, Class of 2007, Health System Pharmacist, RPh. Hematology, Infectious Disease.

  4. #4
    PharmD Year 1 TomHsiung's Avatar
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    Default Re: CC: "Swollen feet and shortness of breath when walking more than half a block"

    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)
    Last edited by TomHsiung; Fri 17th June '16 at 11:02pm.
    B.S. Pharm, West China School of Pharmacy, Class of 2007, Health System Pharmacist, RPh. Hematology, Infectious Disease.

  5. #5
    PharmD Year 1 TomHsiung's Avatar
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    Default Re: CC: "Swollen feet and shortness of breath when walking more than half a block"

    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
    Last edited by TomHsiung; Fri 17th June '16 at 11:07pm.
    B.S. Pharm, West China School of Pharmacy, Class of 2007, Health System Pharmacist, RPh. Hematology, Infectious Disease.

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