Date: ________

CASE STUDY NO: 1

AB, a 60-year-old male admitted as a C.C of increasing shortness of breath and 8kg weight gain.
2 days before admission he noted dyspnea on exertion after 1 flight of stairs. orthopnea, ankle
edema has progressed despite of intermittent chlorthif hydrotherapy of hydrochlorthiazide.3 weeks
before admission he noted onset of proximal nocturnal dyspnea (PND). since then, he has only
been able to sleep in sitting position. AB notes a productive cough and mild dependent edema. His
other medical problems include 4 years history of peptic ulcer, 2-year history of rheumatoid
arthritis which has been managed with NSAID’S, chronic headache managed with
hydrochlorothiazide and propranolol. There is also strong history of Diabetes. Physical
examination reveals dyspneic cyanotic tachycardiac male with following lab values:

 Blood pressure:160/100mmHg
 Pulse:190 beats per min
 Respiratory rate:28 beats/min
 Weight:70 Kg's
His neck vein is distended, liver is enlarged, he has positive hepatojugular reflex and 3 plus pitting
edema of extremities has been observed.
Chest examination reveals inspiratory rales. Medication history reveals following:

 Hydrochlorothiazide: 50mg
 Ibuprofen: 600mg QID
 Allergies: none
 He claims no dietary interactions
LAB VALUES
 HCT:44.1%
 WBC:5300/mm3
 Potassium:3.2
 Sodium:132
 Chloride:90
 Magnesium:1.2
 SBS:120mg
 Uric acid:8mg/dl
 BUN:40mg/dl
 Creatinine:0.8mg/dl
 Alkaline phosphatase:120 units
 AST:100 units
 Chest x-ray shows bilateral pleural effusion and cardiomegaly
Questions:
1. What sign and symptoms and lab abnormalities of CHF and exhibited by
AB?

2. Relate sign and symptoms to pathogenesis of disease and right and left sided
failure?
3. How severe is AB’s disability according to NYHA classification?
4. What possible factors contribute to etiology of AB’s heart disease?

5. B- blocker, NSAIDs and drugs high in sodium were noted as possible cause
of AB’s CHF. What other drugs we have been implicated in the induction of
CHF?
6. Best rest and 1g sodium diet were ordered for AB. What is the drug of 1 st
choice for AB? Diuretic, digoxin or ACE inhibitors?
7. Looking at AB’s lab values can any of abnormal values be attributed to
hydrochlorothiazide that he had been taking?

8. It was decided to begin furosemide for AB? What route dose and dosing
schedule should be used?
9. How will you monitor therapy of furosemide that you recommend?
10. AB’s has to receive digitalis. What baseline information is important to
obtain before admission?

11. Which digitalis glycoside should AB received? Can he be started with

properly chosen maintenance dose or loading dose?
12. What would be appropriate loading dose of digoxin for AB ?

13. Determine appropriate maintenance dose of digoxin?

Date: ______

PROBLEM BASED LEARNING

1. How will you differentiate between right sided and left sided heart failure?

2. Why echocardiogram is used?

3.Why digoxin and CCB are used to treat heart failure as they have opposite
mode of action?

4. What do you mean by Therapeutic drug monitoring of digoxin?