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LEARNING OBJECTIVES

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After completing this case study, the reader should be able to:

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  • Identify the signs and symptoms of acute decompensated heart failure (ADHF).

  • Classify a patient into the appropriate hemodynamic subset based on symptoms and clinical presentation.

  • List goals of therapy for treating ADHF.

  • Develop a pharmacotherapeutic plan for treating a patient with ADHF in the hemodynamic subset presented.

  • Outline a monitoring plan for treating a patient with ADHF in the hospital.

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PATIENT PRESENTATION

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Chief Complaint

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“I can no longer lie down flat because I can’t breathe and I’ve gained 3 pounds in 3 days.”

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HPI

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Bizzy Fuller is a 64-year-old female with a history of ischemic cardiomyopathy with last known EF 25% (ECHO 1.5 years ago). She presents to the emergency department with approximately 2–3 days of increasing shortness of breath, and she reports having gained approximately 3 lb over the past 3 days. She also notes that she has had increasing leg swelling over the same time period. Over the past week, the patient has noted increasing bloating in her abdomen and has felt slightly nauseated. She has had problems with diarrhea and constipation since her cholecystectomy several months ago. She has been on a fiber supplement, from which she has derived some benefit. She states that she had been on torsemide many years ago but for an unknown reason was switched to furosemide.

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PMH

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  • CAD (status postmyocardial infarction × 2 in early 2000s; CABG in 2000, PCI in May 2002)

  • Paroxysmal ventricular tachycardia (status post-ICD placement in 2011)

  • Obstructive sleep apnea

  • Diabetes mellitus type 2

  • Depression

  • Dyslipidemia

  • Mild osteoarthritis

  • GERD

  • Seasonal allergies

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FH

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Both her mother and father died of MI in their 60s

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SH

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Patient is a happily married, retired school teacher and is fully functional with ADLs. She is an occasional alcohol drinker (two to three drinks per week) and has a 30 pack-year history, but quit smoking approximately 12 years ago.

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Meds

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  • Fexofenadine 60 mg orally BID

  • Insulin detemir 40 units SC at bedtime

  • Insulin aspart 7 units SC before each meal

  • Aspirin 81 mg orally once daily

  • Carvedilol 12.5 mg orally BID

  • Duloxetine 30 mg orally once daily

  • Fluticasone nasal spray 50 mcg/inh one spray BID

  • Lasix 80 mg orally BID

  • Lisinopril 20 mg orally once daily

  • Meloxicam 15 mg orally daily PRN joint pain

  • Nitroglycerin 0.4 mg sublingually PRN chest pain

  • Simvastatin 20 mg orally QHS

  • Ranitidine 150 mg orally BID

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All

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NKDA

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ROS

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She denies any fevers, chills, sweats, or coughs. She states that her diet has not changed recently, and she tries to watch her salt intake, but she states ...

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