Question

I.W., aged 62, is a male who is new to your practice. He is reporting shortness of breath on exertion, especially after climbing steps or walking three to four blocks. His symptoms clear with rest. He also has difficulty sleeping at night (he tells you he needs two pillows to be comfortable). He tells you that 2 years ago, he suddenly became short of breath after hurrying for an airplane. He was admitted to a hospital and treated for acute pulmonary edema. Three days before the episode of pulmonary edema, he had an upper respiratory tract infection with fever and mild cough. After the episode of pulmonary edema, his blood pressure has been consistently elevated. His previous physician started him on a sustained-release preparation of diltiazem 180 mg/d. His medical history includes moderate prostatic hypertrophy for 5 years, adult-onset diabetes mellitus for 10 years, hypertension for 10 years, and degenerative joint disease for 5 years. His medication history includes hydrochlorothiazide (HydroDIURIL) 50 mg/d, atenolol (Tenormin) 100 mg/d, controlled-delivery diltiazem 180 mg/d, glyburide (DiaBeta) 5 mg/d, and indomethacin (Indocin) 25 to 50 mg three times a day as needed for pain. While reviewing his medical records, you see that his last physical examination revealed a blood pressure of 160/95 mm Hg, a pulse of 95 bpm, a respiratory rate of 18, normal peripheral pulses, mild edema bilaterally in his feet, a prominent S3 and S4, neck vein distention, and an enlarged liver.

Diagnosis: Heart Failure Class II

Answer the following questions. Include two references, cited in APA style.

List specific goals of treatment for I.W.

What drug(s) would you prescribe? Why?

What are the parameters for monitoring the success of your selected therapy?

Discuss specific patient education based on the prescribed therapy.

Describe one or two drug–drug or drug–food interactions for the selected agent(s).

List one or two adverse reactions for the selected agent(s) that would cause you to change therapy.

What would be the choice for the second-line therapy?

What over-the-counter or alternative medications would be appropriate for this patient?

What dietary and lifestyle changes should be recommended for I.W.?

Answer 1

1) The specific goals of the treatment for I.W are:

• Relief symptoms and improve the quality of life.
• Management of hypoperfusion. and protection of vital organs from further damage (like heart. brain, kidneys)
• slow disease progression.
• Reduce the need of emergency room visits and hospitalization.
• Support to live longer.

2) Medications prescribed for heart failure are:

• Angiotensin converting enzyme (ACE) inhibitors: Its causes vasodilation of arteries which improves the blood flow towards heart and reduces the workload on heart.
• Beta blockers: It lowers the blood pressure and also decrease the effect of harmful hormones that causes disease progression.
• Diuretics: In a patient with heart failure, the excess fluid gets collected around heart increasing its workload. Diuretics help to remove this extra body fluid. Spironalactone is a diuretic that preserves potassium and is seen to reduce the hospitalization.
• Digoxin is used to increase the force of contraction, makes the heart beat stronger and slower. It regulates the rhythm of contraction.
• Anti arrhythmic drugs: its to treat abnormal heart rhythms.

3) In order to monitor the success of the prescribed therapy, following parameters are used:

• symptom and signs of hypoperfusion like cyanosis, tachycardia, tachyopnea, hypotension.
• ?Vital signs and GFR
• Urine output
• Laboratory assessment of troponin, hemoglobin, natriuretic peptides, arterial blood gases, renal function test and electrolytes can provide additional information.
• Radiological examination like xray, doppler echocardiography can evaluate the heart condition after treatment.

4) Patient education based on therapy should include the following:

• Self assessment of symptoms of congestion like shortness of breadth, chest pain, coughing so that exacerbation of disease can be identified.
• Body weight monitoring is crucial as it gives information about the excess fluid which may cause pulmonary edema.
• Dietary modifications includes low sodium diet, low fat, low cholesterol and less water intake.
• Physical activity with frequent rest periods.
• Medication dose adjustments as prescribed.
• Alert tag to seek medical advice.
• Medical checkups and follow up visits.
• Laboratory examinations like RFT, electrolytes within a week, basic chemistry 3 months interval, INR monthly if on warfarin.
• Strict compliance to the drug therapy is advised.