Question

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?

Answer 1

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.