Symptoms: 6/10 substernal chest pain, shortness of breath.

Symptoms: 6/10 substernal chest pain, shortness of breath.

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Vital signs: .4^oF, , , /84.

Other: SaO₂% on RA, 92% on supplemental O₂. ECG showed normal sinus rhythm, no acute abnormalities.

Health history: Hypertension for 20 years. lbs. ”. Hyperlipidemia. 32 pack-year history of smoking. No personal or family history of diabetes or kidney disease. No family history of heart disease. Mr. Martin has a one-month history of progressive dyspnea on exertion, fatigue, abdominal bloating, and lower extremity edema. In the last week he has had 3 episodes of paroxysmal nocturnal dyspnea and orthopnea.

Medications: Hydrochlorothiazide 25mg po daily for last 10 years, simvastatin 20mg daily for last 5 years.

Examination: Mr. Martin was anxious at the time of examination. Jugular venous pressure (JVP) at 5cm above the clavicle. Point of maximal impulse (PMI) displaced laterally. S4, S3 audible. Systolic murmur 3/6, mitral valve regurgitation. Hepatojugular reflex (HJR) present. +1 pitting edema at mid-shin bilaterally.

Laboratory: BNP 1100pg/mL. Serial troponins negative. All other labs negative.

Radiology: CXR showed enlarged cardiac silhouette, mild pulmonary edema without effusion, and consolidation. Echocardiogram revealed left ventricular ejection fraction of 32% with dilatation and no wall motion abnormalities. Serial ECGs were normal.

Summary: Mr. Martin was admitted to a medical-surgical unit. He received diuretic therapy with improvement in his symptoms. BNP reduced to 200pg/mL and other labs remained stable. O₂ normalized on room air. Mr. Martin had a 10-lb. reduction in body weight in 3 days. HJR was resolved and lower extremity edema was significantly improved. PMI lateral displacement remained. S3 resolved. 3/6 mitral regurgitation remained. JVP was at the clavicle.

Discharge medications: furosemide 20mg PO QD, lisinopril 10mg QD, simvastatin 20mg QDHS, carvedilol 3.125mg BID.

1. What signs and symptoms might Mr. Martin have been aware of that could have indicated to him that he was having a health problem? In other words, what are the signs and symptoms of heart failure?
2. What are the signs and symptoms that Mr. Martin came into the hospital with that were indicative of heart failure? Explain the physiology behind each sign/symptom; that is, what is the process that causes each symptom to manifest? For each sign/symptom that improved during his hospitalization, why did it improve?

1. Could Mr. Martin’s previous medications have affected his heart failure? In what ways?

1. Explain Mr. Martin’s other-than-normal examination findings. What is the physiology behind each? Why were his serial troponins negative?

1. Describe how BNP measurements are used in the diagnosis and treatment of heart failure.

1. Mr. Martin was discharged with a diuretic. Why was he not also started on potassium (first, why would he have been started on K⁺)?

1. What assessments should be done at Mr. Martin’s first outpatient follow-up visit?