Pertinents

My basis for clinical impression are the pertinent that are present in the patient:

1. Such as dyspnea - Dyspnea on exertion

2. Orthopnea

3. conscious, coherent, cooperative, in respiratory distress

4. qual chest expansion, coarse crackles on bilateral basal lung fields

5. _________________________-

My clinical impression to the case is

Left sided heart failure and hypertension

Hypertension – modifiable risk factor of having hypertension incude unhealthy diets such as excessive
salt consumption, high saturated fat) no physical activities or exercise, cigarette smoking and
consumption of alcohol. Can also genetics and family history, age and gender of patient is non
modifiable risk which we cannot control.

Hypertension or high blood pressure is a leading risk factor for heart diseases, such as it heart failure
specifically left sided heart failure. High blood pressure add to hearts work load, it will cause
vasoconstriction, it will narrow the arteries make it more difficult for blood to travel efficiently through
the body.

Basically on left atrium and left ventricle contains oxygenated blood from the lungs, when there
is left-sided heart failure the oxygenated blood cannot be pumped up from the heart to the rest of
the body and so blood can backflow and accumulates in the lungs (pulmonary congestion) that
causes leading to shortness of breathing ( it will happen when fluid accumulates In the alveoli)
and it will also cause pulmonary edema and the patient can experience orthopnea, pink frothy
sputum can be observe and paroxysmal nocturnal dyspnea where patient awakens at night
because of difficulty of breathing.

-____________________________________
COPD

- Copd has adverse effect on blood pressure, COPD occurs due to damage and impaired
functioning of the lungs, resulting in difficulty breathing (which is also the chief
complaint of the patient) . The condition leads low oxygen levels. And Over time this can
make the heart work harder and increase blood pressure.
- Dyspenea is a cardinal sign of COPD, the dyspnea dyspnea it cause by airway obstruction
which is secondary to airways infkamation, airways remodeling and sputum
hypersecretion; reduce lung elastic recoil due to emphysema and obstruction of small
airways results in incomplete air expelling and dynamic hyperinflation
- But we can rule out copd since its Symptoms include difficulty of breathing, productive
cough and whezzing which is manifested of the patient in our case. .
- Orthopnea – patients with copd also may experience othopnea after reclining, when fluid
mobilizes in the lungs.
 RULE OUT since the patients have no productive cough

 No Wheezes and rhonchi heard

 Upon inspection there is no Barrel chest-chest deformity which is hallmark of copd

Myocardial ischemia

Myocardial ischemia occurs when blood flow to your heart is reduced, preventing the heart
muscle from receiving enough oxygen. The reduced blood flow is usually the result of a partial
or complete blockage of your heart's arteries (coronary arteries).

Myocardial ischemia, also called cardiac ischemia, reduces the heart muscle's ability to pump
blood. A sudden, severe blockage of one of the heart's artery can lead to a heart attack.
Myocardial ischemia might also cause serious abnormal heart rhythms.

Hypertension itself can cause MI. high blood pressure can also cause ischemic heart disease,
this means that heart muscle isn’t getting enough blood. It is usually result of artherosclerosis
( build up of fats or cholesterol or coronary artery disease which impedes blood flow to the
heart.
I ruled in myocardial ischemia because it has symptoms of tachycardia, dyspnea Those with a history of
a myocardial infarction are also at an increased risk of developing orthopnea. I ruled out myocardial
ischemia because there is no chest pain or chest discomfort present on patients that radiates to left
shoulder neck and jaw pain, is the most common symtoms of myocardial ischemia.
  Hyperthropic cardiomyopathy – one of j factor is long term hypertension.
Hypertension increases the work load on the heart inducing structural and functional changes in
the myocardium This involves abnormal thickening of the heart muscle which make it more
harder for the heart to work. It affects the muscle of the heart main pumping chamber which is
the left ventricle. I ruled in hyperthropic cardiomyopathy because it wll exhbit symptoms of

 of Dyspnea on exertion

 Orthopnea

 Hypertensive

 Tachycardic

 Tachyneic

Rule out because: hypertrophic cardiomyophaty is a diastolic dysfunction. Lower cambers of

heart don’t relax as they should. Left ventricular hypertrophy ( chamber stiffness and impared
relaxation.

left sided heart failure also called heart failre with reduce efection fraction, occurs when left ventricle
cant pump blood efficiently. _______________________________________-

The right side of the heart takes deoxygenated blood that has already been through the heart
and pumps it out into the lungs. The lungs then replenish it with oxygen.

In right sided heart failure, the right ventricle of the heart is unable to pump enough blood to the
lungs.Increased fluid and pressure then pass through the right side of the heart muscle and into
the lungs.

Consequently, the right side of the heart becomes weaker and damaged. There is also a buildup
of blood in the veins, which can cause dispersion of fluid to surrounding tissues. This in turn can
lead to swelling throughout the body, including the:

 legs
 ankles
 abdomen
 gut
 liver
I ruled in right sided heart failure to compared it with left sided heart failure where there
symptoms are overlapping they just differ on site where fluids accumulates.

Basically on left atrium and left ventricle contains oxygenated blood from the lungs, when there
is left-sided heart failure the oxygenated blood cannot be pumped up from the heart to the rest of
the body and so blood can backflow and accumulates in the lungs leading to shortness of breath,
pulmonary edema and the patient can experience orthopnea.