ACTIVITY ON

HEART FAILURE
DRUGS AND
DIURETICS

CASE
AS,

a 59 year old female, is admitted with a

chief complaint of increasing dyspnea and
weight gain of 9 kg. Three weeks before
admission, she noted shortness of breath on
exertion after one flight of stairs, ankle edema,
and inability to lie flat in bed while sleeping.
Since then, her symptoms have worsened. She
also noted episodes of waking up at night due
to breathlessness, and has only been able to
sleep in sitting position. She also reports
productive cough, edema and two to three
episodes of urination at night.

CASE (cont.)
Her

other medical problems include a long

history of heartburn, 10-year history of
osteoarthritis, depression and poorly-controlled
hypertension. Both her parents died of
complications of diabetes.

PHYSICAL EXAMINATION

Vital signs:

BP 160/100
Pulse 90 bpm
RR 28 breaths/min

511
Weight: 78 kg
(+) distended neck
veins

Cardiac Examination:

Height:

(+) S3 gallop, apex

beat loc. At 6th ICS, 12
cm from the MSL
Liver is enlarged w/
tenderness on palpation
(+)hepatojugular reflux

Extremities: (+) grade

3 pitting edema
Chest examination:
bilateral inspiratory
rales and rhonchi

MEDICATION HISTORY
Current

medications:

Hydrocholorothiazide 25 mg/day
Ibuprofen 600 mg/4x a day
Ranitidine 150 mg every night at bed
time
Citalopram 20 mg/day

No allergies and dietary restrictions

ADMITTING LABORATORY EXAMS

AND ANCILLARY PROCEDURES
VALUES
Hct
WBC

41.1%
5300/ul

Na

132 mEq/L

3.2 mEq/L

Cl

100 mEq/L

HCO3

30 mEq/L

Mg

1.5 mEq/L

FBS

100 mg/dL

Uric Acid
BUN

8 mg/dL
40 mg/dL

ADMITTING LABORATORY EXAMS

AND ANCILLARY PROCEDURES
VALUES
SCr

0.8 mg/dl

AlkPhos

44 units/l

AST

30 units/L

BNP

364 pg ml (N <200 pg/ml)

TSH

2 microunits/mL

CXR bilateral pleural effusions and cardiomegaly

PATIENT PROBLEMS
WITH BASES

PATIENT PROBLEMS w/ BASES

Chief

complaint: increasing dyspnea and

weight gain of 9 kg (no specific period of time
indicated)

Weight gain of more than 2 lbs (1 kg) in two days or

5 lbs (2.5 kg) in one week is significant

Clinical Signs and symptoms:

Shortness of breath exertion after one flight
of stairs
Ankle edema
Orthopnea/Inability to lie flat
Paroxysmal Nocturnal Dyspnea
Productive cough
Edema
2-3 episodes of urination at night

DYSPNEA & SHORTNESS OF BREATH

EXERTION AFTER ONE FLIGHT OF STAIRS
Observed in the early stages of heart failure only
during exertion; as disease progresses occurs w/
less strenuous activity and may occur even at rest
Origin is multifactorial; but the most important
mechanism is pulmonary congestion w/
accumulation of interstitial or inta-alveolar fluid
Other factors

reduction in pulmonary compliance

Increased airway resistance
Respiratory muscle or diaphragm fatigue
anemia

PATIENT PROBLEMS w/ BASES

Chief

complaint: increasing dyspnea and weight

gain of 9 kg (no specific period of time indicated)

Weight gain of more than 2 lbs (1 kg) in two days or

5 lbs (2.5 kg) in one week is significant

Clinical Signs and symptoms:

Shortness of breath exertion after one flight of
stairs
Ankle edema
Orthopnea/Inability to lie flat
Paroxysmal Nocturnal Dyspnea
Productive cough
Edema
2-3 episodes of urination at night

ANKLE EDEMA
A

cardinal manifestation of heart failure

Usually symmetric

PATIENT PROBLEMS w/ BASES

Chief

complaint: increasing dyspnea and weight

gain of 9 kg (no specific period of time indicated)

Weight gain of more than 2 lbs (1 kg) in two days or

5 lbs (2.5 kg) in one week is significant

Clinical Signs and symptoms:

Shortness of breath exertion after one flight of
stairs
Ankle edema
Orthopnea/Inability to lie flat
Paroxysmal Nocturnal Dyspnea
Productive cough
Edema
2-3 episodes of urination at night

ORTHOPNEA (inability to lie flat)

and PRODUCTIVE COUGH
Dyspnea

in recumbent position
A later manifestation of heart failure
Results from redistribution of fluid from the
splanchnic circulation and lower extremities into
the central circulation during recumbency w/
resultant increase in pulmonary capillary
pressure
Relieved by sitting upright or sleeping with
additional pillows
Nocturnal cough is a common manifestation of
this process

PATIENT PROBLEMS w/ BASES

Chief

complaint: increasing dyspnea and weight

gain of 9 kg (no specific period of time indicated)

Weight gain of more than 2 lbs (1 kg) in two days or

5 lbs (2.5 kg) in one week is significant

Clinical Signs and symptoms:

Shortness of breath exertion after one flight of
stairs
Ankle edema
Orthopnea/Inability to lie flat
Paroxysmal Nocturnal Dyspnea
Productive cough
Edema
2-3 episodes of urination at night

PAROXYSMAL NOCTURNAL DYSPNEA

and PRODUCTIVE COUGH
Sudden

episodes of shortness of breath which

generally occur 1-3 hours after the patient has
gone to sleep
May manifest as coughing or wheezing
because of increased pressure in the bronchial
arteries leading to airway compression along
with interstitial pulmonary edema leading to
increased airway resistance

PAROXYSMAL NOCTURNAL DYSPNEA

and PRODUCTIVE COUGH

PATIENT PROBLEMS w/ BASES

Chief

complaint: increasing dyspnea and

weight gain of 9 kg (no specific period of time
indicated)

Weight gain of more than 2 lbs (1 kg) in two days or

5 lbs (2.5 kg) in one week is significant

Clinical Signs and symptoms:

Shortness of breath exertion after one flight of
stairs
Ankle edema
Orthopnea/Inability to lie flat
Paroxysmal Nocturnal Dyspnea
Productive cough
Edema
2-3 episodes of urination at night

EDEMA, WEIGHT GAIN and

FREQUENT URINATION
Edema

or fluid retention can cause sudden

weight gain and frequent urination at night

PHYSICAL EXAMINATION

Vital signs:

BP 160/100
Pulse 90 bpm
RR 28 breaths/min

511
Weight: 78 kg
(+) distended neck
veins

Cardiac Examination:

Height:

(+) S3 gallop, apex

beat loc. At 6th ICS, 12
cm from the MSL
Liver is enlarged w/
tenderness on palpation
(+)hepatojugular reflux

Extremities: (+) grade

3 pitting edema
Chest examination:
bilateral inspiratory
rales and rhonchi

PHYSICAL EXAMINATION

Vital signs:
BP 160/100
Pulse 90 bpm
RR 28 breaths/min

BP:

Hypertensive
Pulse rate: Normal
RR: Tachypneic

PHYSICAL EXAMINATION

Vital signs:
BP 160/100
Pulse 90 bpm
RR 28 breaths/min

Height:

511
Weight: 78 kg
(+) distended neck
veins

Provides

estimation for
right atrial pressure
Indicate presence of
tricuspid regurgitation

PHYSICAL EXAMINATION
Evident

in patients
with enlarged and
hypertrophied
right ventricles
Signifies volume
overload

Cardiac

Examination:

(+) S3 gallop, apex

beat loc. At 6th ICS,
12 cm from the MSL
Liver is enlarged w/
tenderness on
palpation
(+)hepatojugular
reflux

PHYSICAL EXAMINATION
Cardiac
Important

sign in
patients with heart
failure; may pulsate
during systole if
tricuspid regurgitation
is present
Later can cause ascites
due to increase
pressure in the hepatic
veins and veins
draining the
peritoneum

Examination:

(+) S3 gallop, apex

beat loc. At 6th ICS,
12 cm from the MSL
Liver is enlarged w/
tenderness on
palpation
(+)hepatojugular
reflux

PHYSICAL EXAMINATION
Cardiac

Examination:

Distention

of neck
veins by the
maneuver of firm
pressure over the
liver
See in tricuspid
regurgitation

(+) S3 gallop, apex

beat loc. At 6th ICS,
12 cm from the MSL
Liver is enlarged w/
tenderness on
palpation
(+)hepatojugular
reflux

PHYSICAL EXAMINATION
Chest

examination: bilateral inspiratory

rales and rhonchi

HEART FAILURE CLASSIFICATION

(AHA)

HEART FAILURE CLASSIFICATION

(AHA)

The patient probably have a Class II (AHA) Heart failure

because she is having shortness of breath of exertion after one
flight of stairs which is just an ordinary activity (although the
case didnt mention if she is only comfortable at rest).