Question

Religion: Roman Catholic
Address: Malabon
Date of Admission: Aug. 2,2020
Time of Admission: 11:30 PM
Chief Complaint: Shortness of breath
Admitting Diagnosis: CHF

History of Present Illness
The patient is a 60-year-old female presenting to the emergency department with acute onset shortness of breath. Symptoms began approximately 2 days before and had progressively worsened with no associated, aggravating, or relieving factors noted. She had similar symptoms approximately 1 year ago with an acute, chronic obstructive pulmonary disease (COPD) exacerbation requiring hospitalization. She uses BiPAP ventilatory support at night when sleeping and has requested to use this in the emergency department due to shortness of breath and wanting to sleep. She denies fever, chills, cough, wheezing, sputum production, chest pain, palpitations, pressure, abdominal pain, abdominal distension, nausea, vomiting, and diarrhea. She does report difficulty breathing at rest, forgetfulness, mild fatigue, feeling chilled requiring blankets, increased urinary frequency, incontinence, and swelling in her bilateral lower extremities that is new onset and worsening. Subsequently, she has not ambulated from bed for several days except to use the restroom due to feeling weak, fatigued, and short of breath. There are no known ill contacts at home. Her family history includes significant heart disease and prostate malignancy in her father. Social history is positive for smoking tobacco use at 30 pack years. She quit smoking 2 years ago due to increasing shortness of breath. She denies all alcohol and illegal drug use. There are no known foods, drugs, or environmental allergies.
Past Medical History
Past medical history is significant for coronary artery disease, myocardial infarction, COPD, hypertension, hyperlipidemia, hypothyroidism, diabetes mellitus, peripheral vascular disease, tobacco usage, and obesity. Past surgical history is significant for an appendectomy, cardiac catheterization with stent placement, hysterectomy, and nephrectomy.
Her current medications include Breo Ellipta 100-25 mcg inhaled daily, hydralazine 50 mg by mouth, 3 times per day, hydrochlorothiazide 25 mg by mouth daily, Duo-Neb inhaled q4 hr PRN, levothyroxine 175 mcg by mouth daily, metformin 500 mg by mouth twice per day, nebivolol 5 mg by mouth daily, aspirin 81 mg by mouth daily, vitamin D3 1000 units by mouth daily, clopidogrel 75 mg by mouth daily, isosorbide mononitrate 60 mg by mouth daily, and rosuvastatin 40 mg by mouth daily
Family History
(+) HPN
(+) Diabetes
(-) Asthma
(-) Cancer
Physical Examination
Initial physical exam reveals temperature 97.3 F, heart rate 74 bpm, respiratory rate 24, BP 104/54, BMI 40.2, and O2 saturation 90% on room air.
Constitutional: Extremely obese, acutely ill-appearing female. Well-developed and well-nourished with BiPAP in place. Lying on a hospital stretcher under 3 blankets.
HEENT:
Head: Normocephalic and atraumatic
Mouth: Moist mucous membranes.
Macroglossia
Eyes: Conjunctiva and EOM are normal. Pupils are equal, round, and reactive to light. No scleral icterus. Bilateral periorbital edema present.
Neck: Neck supple. No JVD present. No masses or surgical scarring.
Throat: Patent and moist
Cardiovascular: Normal rate, regular rhythm, and normal heart sound with no murmur. 2+ pitting edema bilateral lower extremities and strong pulses in all four extremities.
Pulmonary/Chest: No respiratory status distress at this time, tachypnea present, (+) wheezing noted, bilateral rhonchi, decreased air movement bilaterally. Patient barely able to finish a full sentence due to shortness of breath.
Abdominal: Soft. Obese. Bowel sounds are normal. No distension and no tenderness
Skin: Skin is very dry
Neurologic: Alert, awake, able to protect her airway. Moving all extremities. No sensation losses
Admission Order
Initial evaluation to elucidate the source of dyspnea was performed and included CBC to establish if an infectious or anemic source was present, CMP to review electrolyte balance and review renal function, and arterial blood gas to determine the PO2 for hypoxia and any major acid-base derangement, creatinine kinase and troponin I to evaluate presence of myocardial infarct or rhabdomyolysis, brain natriuretic peptide, ECG, and chest x-ray. Considering that it is winter and influenza is endemic in the community, a rapid influenza assay was obtained as well.
CBC
Largely unremarkable and non-contributory to establish a diagnosis.
CMP
Showed creatinine elevation above baseline from 1.08 base to 1.81 indicating possible acute injury. EGFR at 28 is consistent with the chronic renal disease. Calcium was elevated to 10.2. However, when corrected for albumin this corrected to 9.8 mg/dL. Mild transaminitis present as seen in Alkaline Phosphatase, AST, and ALT measurements which could be due to liver congestion from volume overload.
Initial arterial blood gas with pH 7.491, PCO2 27.6, PO2 53.6, HCO3 20.6, and oxygen saturation 90% on room air indicating respiratory alkalosis with hypoxic respiratory features.
Creatinine kinase was elevated along with serial elevated troponin I studies. In the setting of her known chronic renal failure, and in the setting of acute injury indicated by the above creatinine value, a differential of rhabdomyolysis is set.
Influenza A and B: Negative
ECG
Normal sinus rhythm with non-specific ST changes in inferior leads. Decreased voltage in leads I, III, aVR, aVL, aVF.
Chest X-ray
Findings: Bibasilar airspace disease that may represent alveolar edema. Cardiomegaly noted. Prominent interstitial markings noted. Small bilateral pleural effusionsRadiologist Impression: Radiographic changes of congestive failure with bilateral pleural effusions greater on the left compared to the right
.2nd Day of Admission
The second day of the admission patient’s shortness of breath was not improved, and she was more confused with difficulty arousing on conversation and examination. To further elucidate the etiology of her shortness of breath and confusion further history was obtained via the patient’s husband. He revealed that she is poorly compliant with taking her medications. He reports that she “doesn’t see the need to take so many pills. ”Testing was performed to include TSH, free T4, BNP, repeated arterial blood gas, CT scan of the chest, and echocardiogram. TSH and free T4 evaluate hypothyroidism. BNP evaluates fluid load status and possible congestive heart failure. CT scan of the chest will look for anatomical abnormalities. An echocardiogram is used to evaluate for left ventricular ejection fraction, right ventricular function, pulmonary artery pressure, valvular function, pericardial effusion and any hypokinetic area.
TSH: 112.717 (H)
Free T4: 0.56 (L)
TSH and Free T4 values indicate severe primary hypothyroidism
BNP: 187
BNP can be falsely low in obese patients due to the increased surface area. Additionally, adipose tissue has BNP receptors which augment the true BNP value. Also, African American patients more excretion may have falsely low values secondary to greater excretion of BNP.
This test is not that helpful in renal failure due to the chronic nature of fluid overload. This allows for desensitization of the cardiac tissues with a subsequent decrease in BNP release.
Repeat arterial blood gas on BiPAP ventilation shows pH 7.397, PCO2 35.3, PO2 72.4, HCO3 21.2, and oxygen saturation 90% on 2 L supplemental oxygen. CT chest without contrast was mainly obtained to evaluate left hemithorax especially retrocardiac area.
Radiologist Impression: Tiny bilateral pleural effusions. Pericardial effusion. Coronary artery calcification. Some left lung base atelectasis with minimal airspace disease.
Echocardiogram
The left ventricular systolic function is normal. The left ventricular cavity is borderline dilated.
The pericardial fluid is collected primarily posteriorly, laterally but not apically. There appeared to be a subtle, early hemodynamic effect of the pericardial fluid on the right-sided chambers by way of an early diastolic collapse of the RA/RV and delayed RV expansion until late diastole. Dedicated tamponade study was not performed.
Estimated ejection fraction appears to be in the range of 66% to 70%. The left ventricular cavity is borderline dilated.
The aortic valve is abnormal in structure and exhibits sclerosis. The mitral valve is abnormal in structure. Mild mitral annular calcification is present. There is bilateral thickening present. Trace mitral valve regurgitation is present.

1. Conceptualize the pathophysiological alterations distinct to the case.

Answer 1

                    Due to etiological factors such as smoking for 30 years, her airway becomes changed causes alteration in the diameter of airway by increasing number of cells.

Thereby causes increased production of mucus. It makes the airway to clear of secretion and also in the changes in cilia cells. Due to continuing smoking causes airway becomes thickened and also loss of cilia. In same way it changes in the airway space and causes in changes in walls of alveoli

   Due to long standing changes in the respiratory system and smoking, obesity makes the obstructive sleep apnea it again worsening respiratory changes, changes in the alveoli, loss of air space that causes atelectasis . it Is the reason for respiratory symptoms.and it causes increase pressure in the pulmonary artery compensate due to resistance in the pulmonary artery and it makes right ventricle not able to pump out blood from right ventricle to pulmonary artery

              In uncompensated situation it causes right ventricular failure causes stagnation of blood in right ventricle and right atrium. It is the reason cardiovascular specifically right ventricular symptoms

                   Superior and inferior vena cava is become dilated that causes venous pooling of the legs and causes periorbital edema and causes congestion in the liver altered liver enzymes levels. It is the reason for the liver changes and leg changes and cognitive changes

                        In uncompensated status, back flow from the pulmonary vein causes blood stagnated in the left ventricle and left ventricle become borderline dilated. It is the reason for left ventricular changes such as left lung atelectassis

            She has been diagnosed to have RIGHT VENTRICULAR FAILURE due to ACUTE EXCERABATION OF CHRONIC OBSTRUCTIVE PPULMONARY DISEASE

1. She has wheeze in the airway the indicates chronic obstructive pulmonary disease. Sh ehas presented with tacypnea,

2. She is primary hypothyroidism that causes make her obesity and increase blood cholesterol. Her family history also contributes cardiac disease. Even though she was diagnosed to have coronary artery disease, at present, she is not suffering from cardiac disease.   Her left ventricular function is normal. It may be changed due to respiratory in uncompensated status.her ECG shows low voltage dueto failur of heart.

3. Peripheral vascular disease is due to long standing smoking that causes in the blood vessels

4. The changes in the renal system is due to low pumping of heart as a result of left ventricle failure from right ventrcular failure. it causes increase in creatinine levels and had frequency of urination at night time.

5. she has experienced cognitive changes due less blood and oxygen to brain causes anxiety, restlessness

6.she has fatique due to less blood and oxygen supply to bodytissues.

7. she had pleural effusion and pericardial effusion as a result of right ventrcile and left ventrcile failure.

tobacco is the risk factor for all change in the system. additional comorbidity is primary hypothyroididm that causes obstructive sleep apnea.if any respiratory failure occurs that causes changes in the heart. because both are interrelated.if any changes in the heart that causes changes in the respirtaory system