Question

In: Nursing

Agnes is a 63-year old female with a history of a variety of medical problems over...

Agnes is a 63-year old female with a history of a variety of medical problems over the last 3 years. Her history is noted for two myocardial infarctions, hypertension, NIDDM and stasis dermatitis of the left leg. Her surgical history is significant for a coronary bypass approximately one year ago.

Today, Agnes presents with SOB which has progressively gotten worse over the last five days. She has, also been experiencing episodes of SOB during the past four months, especially when she is exerting herself. She fatigues easily and has lost "all my energy to do anything." She also complains of anorexia. Last night she suddenly woke up from her sleep and said "I couldn’t catch my breath" and had a dry cough. She reported that she has been sleeping with two to three pillows at night.

Agnes’ physical examination revealed woman who appeared to be depressed and appeared older than his actual age. Her appearance was disheveled. Her respirations seemed labored and her lips have a “blueish tinge”.

Vitals: BP- 91/84mmHg in the rt. arm; HR- 110/bpm; RR- 26/rpm; Temperature- 98F. On PE: there was a dullness to percussion in the bilateral bases with decreased excursion of the diaphragms, course rhonchi were present and inspiratory crackles are heard in the lower lung fields. Cardiac: there were prominent jugular veins that distended to the mandible. The apical pulse is palpated in the 5ICS, left of the MCL. There was an S3 that was palpable at the apex. S1 and S2 were diminished. A grade 3/6 holosytolic murmur was also present at the apex with radiation to the left axilla. The abdominal wall: the anterior wall is round and soft. The liver edge is palpable and tender. The spleen is not palpable. Peripheral exam of the extremities revealed diminished peripheral pulses in the lower limbs. There was an irregular pulse present. Pitting edema was also present in both lower extremities.

The patient was admitted to the hospital that day.

Laboratory results:

CBC:

WBC count = 8,4000/mm3 with normal differential count

Hb - 14.6g/dL, Hematocrit 40%

Platelet count 290,000/mm3

Chemistries:

Glucose 112mg/dL (non-fasting); BUN 33mg/dL; Creatinine 1.6mg/dL;

Total Bilirubin 1.9gm/dL, Direct Bilirubin 0.3mg/dL;

Total Protein 5.8g/dL, Albumin 3.1g/dL;

Electrolytes:

Sodium 132mEq/L, Chloride 93mEq/L, Potassium 4.0mEq/L, Bicarbonate 23mEq/L; Urine: Specific Gravity 1.032, 1 plus protein, hyaline casts.

Chest X-ray reading:

Marked prominence of the pulmonary vascular shadows (bilateral), bilateral pleural effusions, increased haziness and decreased radiolucency of the lung parachyma (bilateral), increased transverse diameter of the heart.

1. What is Agnes’ diagnosis?

2. What is the cause of Agnes’ diagnosis?

3. What other diagnostic testing does the Agnes need to have ordered? Why?

4. What is the standard treatment for Agnes’ diagnosis?

5. What is the long-term management that Agnes will need to do?

Expert Solution

1) Cardiomegaly: Enlarged heart seen on chest X-ray before other tests are performed to diagnose the specific condition causing your cardiomegaly.

2) The causes of cardiomegaly depend on the underlying diseases and disorders that one may suffer from. It is mostly caused either due to dilation or due to ventricular hypertrophy.

3) Imaging tests are the best way to detect an enlarged heart. These measure your heart’s size, movement of blood throughout the chambers and valves, and your heart’s electrical activity. The following tests will be ordered :-

echocardiogram

chest X-ray

CT scan

electrocardiogram (EKG)

4) Treatment :-

Diuretics to lower the amount of sodium and water in your body, which can help lower the pressure in your arteries and heart

Angiotensin-converting enzyme (ACE) inhibitors to lower your blood pressure and improve your heart's pumping capability

Angiotensin II receptor blockers (ARBs) to provide the benefits of ACE inhibitors for those who can't take ACE inhibitors

Beta blockers to lower blood pressure and improve heart function

Anticoagulants to reduce the risk of blood clots that could cause a heart attack or stroke

Anti-arrhythmics to keep your heart beating with a normal rhythm

#. Surgery or other procedures

If medications aren't enough to treat enlarged heart, medical procedures or surgery may be necessary.

Medical devices to regulate heartbeat. For a certain type of enlarged heart (dilated cardiomyopathy), a pacemaker that coordinates the contractions between the left and right ventricles may be necessary. In people who may be at risk of serious arrhythmias, drug therapy or an implantable cardioverter-defibrillator (ICD) may be an option.

Heart valve surgery. If enlarged heart is caused by a problem with one of your heart valves or if it has caused heart valve problems, you may have surgery to repair or replace the affected valve.

Coronary bypass surgery. If enlarged heart is related to coronary artery disease, your doctor may recommend coronary artery bypass surgery.

Left ventricular assist device (LVAD). If there is heart failure, may need this implantable mechanical pump to help your weakened heart pump.

Nightingale answered 2 years ago

. The patient was a 77-year-old female admitted with Congestive Heart Failure, and past medical history...

. The patient was a 77-year-old female admitted with Congestive Heart Failure, and past medical history of an Acute MI, four to six months before admission date. She had been taking Lasix 40mg PO BID and Cardizem 30 mg TID. In a report, I heard that her last O2 saturation was 77% on 3 liters via nasal cannula. Vital signs- afebrile, HR 108, RR 22, BP 148/88. She had an IV of D5W at KVO, the EKG was done, and...

A 22 year old female with no previously known medical history presented to her primary care...

A 22 year old female with no previously known medical history presented to her primary care doctor for a 2 month history of intermittently increased spasticity of her upper extremities and intermittent paralysis of her lower extremities with no known cause. She states that her symptoms seem to “come and go” without a known cause, usually worse in the mornings. Her biomedical engineering college professors have not been very accommodating to her symptoms, however, and have instructed her to be...

: A 73-year-old female admitted to hospital with aspiration pneumonia and sepsis. Past medical history of...

: A 73-year-old female admitted to hospital with aspiration pneumonia and sepsis. Past medical history of multiple CVA’s, PEG tube feeding, multiple pressure ulcers. Patient able to open eyes but not able to follow any commands or respond verbally. Patient came to hospital from home with her wife. On admission, the wife was adamant that the patient be a full code. Wife seemed to be unclear regarding patient’s current medical/functional condition, and the health care team felt that due to...

A 63-year-old woman reports for her annual physical examination. She has no major previous medical history...

A 63-year-old woman reports for her annual physical examination. She has no major previous medical history but does have a recent history of a broken wrist she sustained after a mild fall. Three years ago her height was recorded at 5’3” and is now recorded at 5’1”. She complains that she can’t be quite as active as she used to be and that her back is beginning to bother her. This leads her to be outside less frequently. Her physician...

Roman is a 63 year old male with a history of alcoholism. He presents with a...

Roman is a 63 year old male with a history of alcoholism. He presents with a erythematous, shiny, raised, hardened but tender plaque on his left cheek and nose. The plaque has a distinct border. Romansays that he woke up two days ago feeling “a little off” and experienced chills throughout the day. The facial rash progressively worsened yesterday. His temperature is elevated (39°C or 102.2°F). A sample is collected from one of the lesions, however, no obviously pathogenic organisms...

Consider the following patient scenario: “Agnes, an 82-year-old female, is 168.02 cm. (1.6802 m.) in height...

Consider the following patient scenario: “Agnes, an 82-year-old female, is 168.02 cm. (1.6802 m.) in height and weighs 62.36 kg. She has longstanding type II diabetes mellitus and was diagnosed with ESRD in 2008, and has been on HD since that time. Since 2015, she has been receiving outpatient dialysis treatments at a facility that qualifies for the LV adjustment, because it has never had a treatment volume exceeding 4000 treatments since it opened in 2005. On April 1, 2015,...

A 45-year-old female with a past medical history of Type II Diabetes Mellitus (last hemoglobin A1c...

A 45-year-old female with a past medical history of Type II Diabetes Mellitus (last hemoglobin A1c of 12, currently on intensive insulin therapy), tobacco abuse (approximately 2 packs/day for the last 15 years), and thyroid cancer (anaplastic carcinoma, status post total thyroidectomy) presents to her family nurse practitioner with complaints of a sore throat, cough productive of thick sputum which appears “green,” and subjective fevers and chills (though her temperature has never been above 98.5 degrees Fahrenheit). She states that...

Consider the client's case history: 30 year-old female with gradual hearing loss over the last 3...

Consider the client's case history: 30 year-old female with gradual hearing loss over the last 3 years. Her older sister reports problems hearing since about the age of 18. She reports a light roaring sound in her left ear, no problem with dizziness, otalgia, pressure or otorrhea. The audiologist is suspicious of otosclerosis but needs an ENT to make the official diagnosis.

Veldora is a 63-year-old female that was brought to the emergency room (ER) in acute respiratory...

Veldora is a 63-year-old female that was brought to the emergency room (ER) in acute respiratory distress. She was showing signs of sepsis including hypotension, tachycardia, and a temperature of 39oC. Her lactic acid level and white blood cell (WBC) count came back elevated. She was admitted to the intensive care unit (ICU) with a diagnosis of severe sepsis secondary to pneumonia. She was put on vancomycin, ceftriaxone, levophed and morphine for pain. Veldora had to be intubated on her...

a. Mrs. Ho is a 55 year old female with a five year history of type...

a. Mrs. Ho is a 55 year old female with a five year history of type 2 diabetes and hypertension. She has been brought into the ER via an ambulance. While at home watching TV on her sofa, she developed crushing sub-sternal chest pain (9/10) which radiates to her back and left arm. She took a S.L. nitroglycerin and five minutes later took another when the pain did not subside. She called 911. She is very frightened because her chest...