Kentrick Neil C.

Quiblat Grp 4 Sub-Group 1

Gullas College of Medicine

Internal Medicine SGD Group 4

Case 2. Heart Failure

1. Does this patient have congestive heart failure? If so, what aspects of history and physical exam support
the diagnosis of CHF? What other clinical findings would you look for?
-Yes, the patient has congestive heart failure
-Orthopnea
-Paroxysmal Nocturnal Dyspnea
-Uncontrolled Hypertension
-Type 2 Diabetes Mellitus
- “copper wiring" changes with A-V nicking of the fundi
- JVP estimated at 12 cm H2O
- PMI is diffuse, sustained and is felt lateral to the anterior axillary line
- regular heart rhythm but tachycardia, Left Ventricular Hypertrophy
- S1 is diminished in intensity; S2 is loud and there is evidence for an S4 and S3.
- ascites
- heart size enlarged; + Kerley B lines + bilateral alveolar interstitial edema with bilateral pleural
effusions
-smoker
-alcohol drinker
2. What are the most common underlying etiologies of systolic heart dysfunction leading to congestive
heart failure?
- idiopathic dilated cardiomyopathy (DCM), coronary heart disease (ischemic), hypertension, and
valvular disease

3. What are the most common etiologies of diastolic dysfunction? Which would be most likely in this
patient?
- systemic hypertension with associated comorbidities such as diabetes mellitus, chronic kidney disease,
coronary artery disease, and atrial arrhythmias
-in this patient, Type 2 Diabetes Mellitus or coronary artery disease. because DM increases the risk for
CAD

4. What is the pathophysiology of the diminished S1, loud S2, and audible S4 and S3 sounds? What is the
most likely source of the heart murmur?
-diminished S1 may indicate acute severe aortic regurgitation
-loud S2 may indicate pulmonary hypertension or congenital heart disease involving one of the
semilunar valves
-audible S3 may indicate increased ventricular filling due to congestive heart failure or severe mitral or
tricuspid regurgitation
-audible S4 indicates forceful atrial contraction into a hypertrophied left ventricle

5. Is there a role for echocardiography or stress testing for this patient?

-echocardiography is use to visualize the size, shape, heart chambers and valves of the heart
-stress test is use to measure the health of the heart by how it responds to stress during exertion
6. Identify at least three factors responsible for the patient’s inability to adhere to medical regimen? What
steps might you take to assure long term adherence in the future?
- lack of money due to unemployment
-no health insurance
- rarely keeps his clinic appointments
-uninformed that some medication for hypertension and DM are free

-for the future, educate the patient about the availability of the medication in health centers.
-tell the patient about the serious consequences of not adhering to maintenance medication, stop
smoking and alcohol consumption

7. What acute medical interventions would you pursue to initially treat the pulmonary edema?
-Oxygen supplementation
-Give diuretics to the patient
-
8. What pharmacologic interventions should be considered for therapy on a chronic basis? Which ones
have been shown to improve survival for patients with chronic CHF?

-Beta Blocker therapy shows improved survival of patients with chronic CHF