11 Advanced Health Assessment Student’s name Institutional Affiliation Course Name and Number

11

Advanced Health Assessment

Student’s name

Institutional Affiliation

Course Name and Number

Instructor’s Name

Date

Advanced Health Assessment

Patient Initials: K.R Date of Birth: 04/14/1972 Sex: Female Race: White Ethnicity: Non-Hispanic Date of Encounter: 07/05/2024

Subjective

Chief Complaint: “I have been having difficulties in breathing especially when I lie down flat when walking up the stairs, wake up at night and move to the widow to catch some breath and can only sleep when sitting upright or with several pillows, and swelling of my legs for now 2 months”

Source and Setting: The patient reported at the outpatient department from home accompanied by her daughter and son.

History of Present Illness: K.R. is a 52-year-old Non-Hispanic white American female who presented with a two-month history of difficulty breathing especially when lying down flat on her back and performing activities such as climbing up the stairs. She reports sleeping only while sitting upright, or with several pillows placed to almost an upright position. She however does not experience difficulties breathing when performing activities of daily living such as dressing or combing her hair. Besides, she also reports experiencing difficulty breathing while sleeping at night and wakes up frequently to reach the window to catch some air. She also reports noticing swelling in her lower limbs, especially at the ankle. There are however no associated pain, numbness, or experiencing difficulty walking. There is also no associated flank pain, no increased frequency of urination, no urethral discharge, facial puffiness, or dysuria reported. She mentions that she has had difficulty maintaining her medication regimen due to the recent move and has yet to find a local pharmacy. The symptoms have been progressively worsening, and now have limited her ability to perform various activities including working at her farm and even walking up and down stairs as she initially used to without having any difficulties.

Past Medical History:

The patient was diagnosed with type 2 diabetes mellitus 21 years ago and had been having proper glycemic control until 4 months ago when she recently moved to this region and ran out of medications and failed to refill them in time as she had not found a local pharmacy. She has also been hypertensive for the past 6 years, which has been well controlled until the last 4 months when she reports poor compliance due to a change of locality and having not refilled her medications. She was also diagnosed with dyslipidemia and was recommended lifestyle modifications and lipid-lowering agents. She is up to date with vaccinations, including the yearly influenza vaccine, and does not suffer from other chronic conditions for intake kidney disease or coronary artery disease.

Surgical History

She has not had any past minor or major surgeries, except for a Cesarean section twice when she was 27 and 30 which had no complications.

Medications:

Metformin 1000 mg BID (reports inconsistent use)

Lisinopril 10 mg daily (reports inconsistent use)

Amlodipine 5 mg daily (reports inconsistent use)

Atorvastatin 20mg daily (reports inconsistent use)

Allergies:

No known drug, environmental, food, or seasonal allergies were reported.

Family History:

The mother is deceased while aged 75 due to heart failure. The father is also deceased at 72 due to kidney failure secondary to type 2 diabetes mellitus. She has 3 siblings, one is hypertensive, while the remaining two are all alive and well.

Social History:

She occasionally drinks alcohol and smokes at least a stick of cigarettes a day despite advice from doctors to quit smoking and stop drinking. She lives alone after separating from her husband, as her children live in a different state and only visit occasionally. She is currently not in any relationship and is not sexually active. She used to work as a counselor but has since stopped working due to her worsening health condition. She does not have any advance directives, but blood transfusion is allowed during an emergency. She follows a strict non-fatty diet as advised due to her dyslipidemia state, and does not engage in exercise as she experiences breathlessness. She does not use recreational or illicit drugs but reports a moderate level of caffeine consumption. She does not have any symptoms of the Zika virus, has not traveled to Zika-affected areas within the last 12 weeks, uses seat belts routinely, and does report difficulties in some activities of daily living such as climbing up her home stairs.

Review of Systems:

General: reports fatigue, and unintentional weight loss; denies night sweats, fever, or chills

Skin: Denies rashes or skin color changes

Eyes: Denies eye pain or visual disturbances.

Ears: Denies difficulty hearing tinnitus, or ear discharge

Nose/Mouth/Throat: Nose: Denies rhinorrhea, epistaxis, snoring, sore throat, or gingival bleeding.

Breast: Denies breast pain, mass, or nipple discharge/pain

Heme/Lymph/Endo: Reports reduced appetite, dizziness, and syncope; denies irregular menses or hot flashes.

Cardiovascular: Reports orthopnea, edema, PND, dyspnea on exertion, and chest pain; Denies arm pain on exertion, known heart murmur, or leg cramping.

Respiratory: Reports dyspnea on exertion, and chest pain; denies cough, sleep apnea, or hemoptysis.

Gastrointestinal: Reports right upper quadrant abdominal pain; denies vomiting, hematochezia, diarrhea, or loss of bowel control.

Genitourinary/Gynecological: Denies dysuria, hematuria, frequency, irregular spotting, flank pain, or malodorous urine

Musculoskeletal: Reports lower extremity swelling; denies muscle aches or weakness, joint swelling or warmth.

Neurological: Denies syncope, weakness, numbness, seizures, headaches, tremors or disorientation.

Psychiatric: Reports feeling depressed and anxious; denies hallucinations or suicidal thoughts.

Objective

Physical Exam:

Vital Signs:

BP: 160/90 mmHg; HR: 88 bpm; RR: 20 breaths/min; Temp: 98.6°F; O2 Sat: 94% on room air

General: Alert and oriented, appears fatigued

Skin: no rashes, open sores, or wounds

HEENT: Eyes: No visual changes, intact extraocular movements, no subconjunctival hemorrhage. Or discharge, no ear discharge or bulging of the tympanic membrane; Neck: supple with no lymphadenopathy or stiffness

Cardiovascular: Extremities: lower limb pitting edema to the ankle level, jugular venous distention, laterally displaced apex beat, S1, and S2 heart sounds heard, no murmur heard on auscultation.

Respiratory: unlabored breathing, no audible wheeze or stridor, with a normal respiratory rate. Bilateral basilar rales audible on auscultation.

Gastrointestinal: Inspection non-distended, symmetrical, no flank fullness, right upper quadrant tenderness on palpation, no organomegaly, bowel sound present on auscultation with no bruits or thrills.

Breast: Symmetrical, no lump, nipple retraction, no pain on palpation, no nipple discharge or axillary lymphadenopathy.

Musculoskeletal: Lower limb bilateral pitting edema to the ankle level, no joint, muscle, or bone tenderness, and exhibits a full range of motion across all joints.

Neurological: well-oriented with no focal deficits.

Psychiatric: appropriate affect, mood, normal speech, and comprehension with intact memory; no suicidal ideation, intent, or plan or homicidal ideation, intent, or plan.

Diagnostic Tests

Based on the patient’s clinical presentation, the relevant diagnostic tests include initial workups such as complete blood count to screen for anemia and signs of infections, basic metabolic panel to assess for creatinine levels and rule out cardiorenal syndrome, HbA1c to monitor the control of sugar over the past 4 months, liver function tests to identify confirm hepatic venous congestion, lipid panel to assess the severity of dyslipidemia, iron studies to assess for iron deficiency, thyroid function tests to assess for thyroid function and cardiac troponin T/I for risk stratification (Arrigo et al., 2020). Basic natriuretic peptide (BNP) is also crucial in confirming the diagnosis of heart failure and assessing the severity and prognosis of the disease.

The preferred initial imaging modality in this patient will be the transthoracic echocardiogram (TTE), to assess for ventricular dysfunction, ejection fraction, and evidence of complications as well as underlying causes for instance left ventricular hypertrophy (Arrigo et al., 2020). Other relevant imaging studies for this patient include a chest X-ray to assess the cardiac structure and size as well as identify any signs of pulmonary congestion. 12-lead ECG is also crucial to assess for abnormalities related to heart failure such as signs of ventricular hypertrophy. There are also advanced studies for instance cardiac MRI to assess ventricular mass, volume, and ejection fraction. Although expensive, right heart catheterization is also useful in this case to assess the right heart function and pulmonary vascular resistance (Arrigo et al., 2020).

Diagnosis and Differentials

Based on the patient’s history and physical examination findings, the most likely diagnosis is heart failure. This is most likely secondary to hypertension and diabetes, as the patient reports inconsistent and poor compliance with the antihypertensive and anti-diabetics. Additional issues that the patient has that require medical attention include hypertension, diabetes mellitus, and dyslipidemia. Other potential diagnoses, although less likely include kidney failure and pulmonary conditions such as obstructive lung disease such as COPD.

Summary Statement

In summary, K.R. is a 52-year-old non-Hispanic white American female who presents at the clinic today with a history strongly suggestive of heart failure secondary to poorly controlled hypertension and diabetes. This is secondary to poor compliance as the patient recently moved to the area and does not have a local pharmacy where she can refill her medications, and also stays alone so has no one to help her move around. The patient has a family history of heart failure and diabetes, and the signs and symptoms, as well as examination findings, are suggestive of heart failure hence the need to conduct the above-mentioned tests to confirm the diagnosis and guide the management plan.

Assessment and Plan

The most likely diagnosis is heart failure secondary to poorly controlled hypertension and diabetes mellitus. The management would involve addressing the underlying causes, which are, hypertension and diabetes mellitus. The patient should have the medications refilled, and get counseled on the need for medication adherence. She should also be educated on various lifestyle modifications for instance aerobic exercise, weight loss, healthy eating patterns such as avoiding excessive dietary sodium, smoking cessation and avoidance of alcohol, and encouraging healthy eating patterns such as the DASH diet.

The patient should also be educated on the need for home blood pressure monitoring, and monitoring of the symptoms for progression and severity (Jaarsma et al., 2021). Besides, she also requires vaccinations for instance pneumococcal vaccine, COVID-19, and seasonal influenza vaccine. There is also a need to assess and address factors associated with poor self-care for instance in this case the social situation at home and advise her children on the need to support and care for her at home upon discharge (Abdin et al., 2021). The patient should also be advised to avoid or use with caution drugs such as NSAIDs, thiazolidinedione, antidepressants, and nondihydropyridine calcium channel blockers as these drugs may worsen heart failure.

Given that the patient has comorbidities that have contributed to the development of her current state, they should be appropriately managed for instance effective treatment of the hypertension to achieve a target of less than 130/80mmHg. For diabetes mellitus, the management should be changed from metformin to sodium-dependent glucose transporter inhibitors such as empagliflozin. The patient should also continue with lipid-lowering agents such as atorvastatin as earlier initiated and adhere to the lifestyle modifications as advised (Seferović et al., 2021).

Pharmacological management of heart failure in addition to the management of the underlying causes as have been identified should be guided by the heart failure staging and the left ventricular ejection fraction. If the patient has heart failure with reduced ejection fraction, initial management should be done using diuretics if the patient has congestion, angiotensin receptor-neprilysin inhibitors (ARNIs) such as Sacubitril/valsartan, beta-blockers such as carvedilol, SGLT2 inhibitors such as empagliflozin and mineralocorticoid receptor antagonists (MRAs) such as spironolactone (Abdin et al., 2021).

The drugs are associated with better prognosis as they reduce morbidity, mortality, and hospitalization rates. For patients with heart failure with preserved ejection fraction, first-line agents include the SGLT2i, or loop diuretics such as furosemide in case the patient has congestion as is in this case. It is also important to screen for any complications such as cardio-renal symptoms and manage them accordingly (Abdin et al., 2021). Following initial management, the patient should be followed up two weeks following discharge to assess the progress, adjust medications accordingly, and address any concerns or issues that the patient may have.

References

Abdin, A., Bauersachs, J., Frey, N., Kindermann, I., Link, A., Marx, N., … & Böhm, M. (2021). Timely and individualized heart failure management: need for implementation into the new guidelines. Clinical Research in Cardiology, 110(8), 1150-1158. https://link.springer.com/article/10.1007/s00392-021-01867-2

Arrigo, M., Jessup, M., Mullens, W., Reza, N., Shah, A. M., Sliwa, K., & Mebazaa, A. (2020). Acute heart failure. Nature Reviews Disease Primers, 6(1), 16. https://www.nature.com/articles/s41572-020-0151-7

Jaarsma, T., Hill, L., Bayes‐Genis, A., La Rocca, H. P. B., Castiello, T., Čelutkienė, J., … & Strömberg, A. (2021). Self‐care of heart failure patients: practical management recommendations from the Heart Failure Association of the European Society of Cardiology. European journal of heart failure, 23(1), 157-174. https://onlinelibrary.wiley.com/doi/abs/10.1002/ejhf.2008

Seferović, P. M., Vardas, P., Jankowska, E. A., Maggioni, A. P., Timmis, A., Milinković, I., … & Voronkov, L. (2021). The heart failure association atlas: heart failure epidemiology and management statistics 2019. European journal of heart failure, 23(6), 906-914. https://onlinelibrary.wiley.com/doi/abs/10.1002/ejhf.2143