WEEK #3 I HUMAN CASE STUDY (CLASS 6550)REASON FOR ENCOUNTER : SHORTNESS OF BREATH..….. A, Exams of Health sciences

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WEEK # 3 I HUMAN CASE STUDY (CLASS 6550)REASON FOR

ENCOUNTER : SHORTNESS OF BREATH..….. A 60-YEAR-OLD

FEMALE – LOCATION :OUTPATIENT CLINIC WITH X-RAY, ECG,

AND LABORATORY CAPABILITIES (2024 CASE STUDY)

INCLUSIVE OF HISTORY QUESTION ANSWERS ACTUAL

SCREENSHOT.

Patient Information

• Age : 60 years old

• Gender : Female
• Height : 5'4" (163 cm)
• Weight : 183 lbs (83.2 kg)
• BMI : 31.4 (Obese category, which may have implications for respiratory and cardiovascular health)
• Reason for Encounter : Shortness of breath
• Location : Outpatient clinic equipped with x-ray, ECG, and laboratory capabilities

History History of Present Illness (HPI)

The patient reports experiencing shortness of breath (SOB) for the past two weeks. The SOB is described as progressive, worsening with exertion, and relieved partially by rest. She denies any sudden onset but notes that it worsens when lying flat (orthopnea). She reports occasional coughing but denies productive sputum, fever, or chills. Associated symptoms include intermittent chest tightness and mild fatigue. She denies wheezing, hemoptysis, dizziness, or syncope. No history of recent travel, surgery, or immobilization. Past Medical History

• Hypertension (diagnosed 10 years ago, controlled with medication)
• Diabetes Mellitus Type 2 (on oral hypoglycemics, HbA1c: 7.2% last checkup)
• Hyperlipidemia
• Obesity
• No known history of asthma, COPD, or heart failure Surgical History
• Appendectomy (age 20)
• Cholecystectomy (age 45) Family History
• Mother: Hypertension and stroke (deceased at 76 years)
• Father: Heart disease (deceased at 68 years)
• Siblings: Two with hypertension and diabetes Social History

• Smoking : 1 pack/day for 30 years, quit 5 years ago (30-pack year history)
• Alcohol Use : Occasional, 1-2 drinks/week
• Occupation : Retired teacher, previously exposed to chalk dust in poorly ventilated classrooms
• Exercise : Minimal due to fatigue and shortness of breath Medications
• Metformin 1000 mg BID
• Lisinopril 20 mg daily
• Atorvastatin 40 mg nightly Allergies
• Penicillin (rash) Physical Exam General Appearance The patient appears overweight, mildly anxious, and slightly tachypneic at rest. No cyanosis or pallor noted. Vital Signs
• Temperature : 98.6°F (37°C)
• Heart Rate : 92 bpm, regular
• Respiratory Rate : 22 breaths/min
• Blood Pressure : 148/86 mmHg
• Oxygen Saturation : 93% on room air

Respiratory System

• Inspection : No visible use of accessory muscles. Chest wall symmetric.
• Auscultation : Bibasilar crackles, no wheezes.
• Percussion : Normal resonance bilaterally.
• Palpation : No tenderness or deformity. Cardiovascular System
• Inspection : No jugular vein distention (JVD).
• Auscultation : Regular rate and rhythm. Soft systolic murmur at the left sternal border.
• Palpation : No heaves or thrills. Abdomen
• Non-tender, no hepatosplenomegaly. Extremities
• Mild bilateral pedal edema, pitting (1+). No clubbing or cyanosis.

Assessment Differential Diagnoses

1. Congestive Heart Failure (CHF) o SOB exacerbated by exertion and orthopnea o Bibasilar crackles and pedal edema
2. Chronic Obstructive Pulmonary Disease (COPD) o Smoking history o Shortness of breath and reduced oxygen saturation
3. Pneumonia o Crackles noted on auscultation o No fever, chills, or sputum production (less likely but not ruled out)
4. Pulmonary Embolism (PE) o SOB and tachypnea o No recent immobilization or leg swelling (less likely)
5. Anemia o Fatigue and SOB with exertion Testing Laboratory Tests

• Complete Blood Count (CBC) : Rule out anemia or infection
• Basic Metabolic Panel (BMP) : Assess for electrolyte imbalances
• B-type Natriuretic Peptide (BNP) : Evaluate for heart failure
• Arterial Blood Gases (ABG) : Assess oxygenation and acid-base status

Imaging

• Chest X-Ray : Evaluate for pulmonary edema, cardiomegaly, or infiltrates
• CT Pulmonary Angiography (if PE suspected) Cardiac Workup
• Electrocardiogram (ECG) : Assess for arrhythmias or ischemia
• Echocardiogram : Evaluate left ventricular function

Diagnosis

Based on the findings, the most likely diagnosis is Congestive Heart Failure (CHF) with preserved ejection fraction due to diastolic dysfunction. Plan

1. Immediate Management o Administer supplemental oxygen if saturation falls below 92% o Initiate diuretic therapy (e.g., furosemide) to reduce fluid overload
2. Medications o Optimize current antihypertensives (e.g., adjust lisinopril dosage) o Consider adding beta-blockers if CHF diagnosis is confirmed
3. Lifestyle Modifications o Low-sodium diet o Weight loss and gradual exercise
4. Patient Education o Recognize signs of worsening heart failure o Importance of medication adherence
5. Follow-Up o Schedule a follow-up in 1-2 weeks to review test results and clinical progress

Summary A 60-year-old female presents with progressive shortness of breath, associated with orthopnea, crackles on auscultation, and pedal edema. History and clinical findings strongly suggest CHF as the primary diagnosis. Testing and management are focused on confirming the diagnosis, addressing symptoms, and preventing further complications. Patient Information

• Demographics : Ensure the patient's full medical history aligns with her age, weight, and height. o BMI calculation: 31.4 (Obese category, raising risks for CHF, diabetes complications, and pulmonary issues). o Include any cultural or socio-economic factors that may influence her healthcare.

History HPI Expand the duration, severity, and context of symptoms:

1. Onset : Was the shortness of breath sudden or gradual? Any prior similar episodes?
2. Triggers : What activities worsen the SOB? (e.g., climbing stairs, walking).
3. Associated Symptoms : o Chest tightness : Any radiating pain? Frequency and intensity? o Cough : Describe its quality—dry, wet, productive, or not. Past Medical History (PMH) Include potential long-term complications of hypertension and diabetes:

• Is there a history of retinopathy, nephropathy, or neuropathy?
• Could the patient's chronic diseases contribute to fluid overload?

Social History

1. Environmental factors : Has exposure to poor ventilation (dusty classrooms) contributed to respiratory conditions?
2. Living situation : Does she live alone? Any caregiver or family support? Medication Review

• Is she adhering to her prescribed medications?
• Any reported side effects like persistent cough from Lisinopril?

Physical Exam Expand on notable findings:

1. General Appearance : o Anxiety or labored breathing may indicate respiratory distress.
2. Respiratory Exam : o Bibasilar crackles suggest pulmonary congestion from CHF. Document crackle location and progression. o Absence of wheezing makes asthma or COPD less likely.
3. Cardiac Exam : o The systolic murmur: Could it indicate valve disease (e.g., aortic stenosis or mitral regurgitation)?
4. Peripheral Findings : o Bilateral pedal edema points to systemic fluid overload rather than localized injury.

Assessment Differential Diagnoses

1. Congestive Heart Failure (CHF) :

o Prioritize exploring diastolic vs. systolic dysfunction. o Consider underlying causes: long-standing hypertension, diabetes, or obesity.

2. Chronic Obstructive Pulmonary Disease (COPD) : o Smoking history is significant but lack of wheezing diminishes this likelihood.
3. Pneumonia : o Fever/chills absent, but must consider mild/atypical presentations.
4. Pulmonary Embolism : o Elevated suspicion if tachycardia or pleuritic chest pain occurs.
5. Anemia : o Rule out with CBC and explore chronic diseases causing low hemoglobin.

Testing Expanded Plan

1. Laboratory Tests : o CBC: Focus on hemoglobin, hematocrit, and white blood cell count. o Electrolytes: Look for imbalances like hypokalemia from diuretics.

o BNP: Elevated levels strongly suggest CHF.

2. Imaging : o X-ray: Look for evidence of pulmonary congestion or pleural effusion. o CT if PE suspicion increases: Must be done if tachypnea worsens.
3. Cardiac Workup : o Echocardiogram: Essential to confirm ejection fraction and diastolic function.

Diagnosis Confirm Congestive Heart Failure (CHF) with evidence from clinical findings, BNP, imaging, and echocardiogram. Evaluate whether the cause is due to preserved ejection fraction (HFpEF) or reduced ejection fraction (HFrEF).