Patient Encounter Part 4

After 6 months, BE returns to clinic complaining of extreme SOB with any activity, including dressing and showering, as well as at rest. She sleeps sitting up due to severe orthopnea, is unable to eat without nausea, and states she has gained 10 kg (22 lb) from her baseline weight. She also states that she does not feel her furosemide therapy is working. She is admitted to the cardiology unit.

SH: BE admits to resuming smoking after quitting for 2 months; additionally, she has been eating out in restaurants more often in the past 2 weeks.

Meds: Lisinopril 10 mg once daily; furosemide 80 mg twice daily; glipizide 10 mg twice daily for diabetes; metformin 1,000 mg twice daily for diabetes; nitroglycerin 0.4 mg sublingual (SL) as needed; multivitamin daily; Aspirin 325 mg daily

VS: BP 146/94 mm Hg, pulse 102 bpm and regular, RR 22/min, temperature 37°C (98.6°F), Wt 123 kg (271 lb), BMI 41.2

Lungs: There are rales present bilaterally

CV: RRR with normal Si and S2; there is an S3 and an S4; a 4/6 systolic ejection murmur is present and heard best at the left lower sternal border; point of maximal impulse is displaced laterally; jugular veins are distended, JVP is 11 cm above sternal angle; a positive HJR is observed

Abd: Hard, tender, and bowel sounds are absent; 3+ pitting edema of extremities is observed

CXR: Bilateral pleural effusions and cardiomegaly Echo: EF 20%

Labs: BNP 740 pg/mL (740 ng/L or 214 pmol/L), K 4.2 mEq/L (4.2 mmol/L), BUN 64 mg/dL (23 mmol/L), SCr 2.4 mg/dL (212 mmol/L), Mg 1.8 mEq/L (0.9 mmol/L)

A pulmonary catheter is placed, revealing the following: PCWP 37 mm Hg; CI 2.2 L/min/m

What NYHA FC, ACC/AHA stage, and hemodynamic subset is BE currently in? What are your initial treatment goals?

What pharmacologic agents are appropriate to use at this time?

Identify a monitoring plan to assess for efficacy and toxicity of the recommended drug therapy.

Once BE's symptoms are improved, how would you optimize her oral medication therapy for HF?

Ventricular Assist Device

The ventricular assist device (VAD) is a surgically implanted pump that reduces or replaces the work of the right, left, or both ventricles. VADs are currently indicated for short-term support in patients refractory to pharmacologic therapies, as long-term bridge therapy (a temporary transition treatment) in patients awaiting cardiac transplant, or in some instances, as the destination therapy (treatment for patients in lieu of cardiac transplant for those who are not appropriate candidates for transplantation).1 The most common complications are infection and thromboembolism. Other adverse effects include bleeding, air embolism, device failure, and multiorgan failure.

Surgical Therapy

Heart transplantation represents the final option for refractory, end-stage HF patients who have exhausted medical and device therapies. Heart transplantation is not a cure, but should be considered a trade between a life-threatening syndrome and the risks associated with the operation and long-term immunosuppression. Assessment of appropriate candidates includes comorbid illnesses, psychosocial behavior, available financial and social support, and patient willingness to adhere to lifelong therapy and close medical follow-up.1 Overall, the transplant recipient's quality of life may be improved, but not all patients receive this benefit. Posttransplant survival continues to improve due to advances in immunosuppression, treatment and prevention of infection, and optimal management of patient comorbidities.

Supplements For Diabetics

Supplements For Diabetics

All you need is a proper diet of fresh fruits and vegetables and get plenty of exercise and you'll be fine. Ever heard those words from your doctor? If that's all heshe recommends then you're missing out an important ingredient for health that he's not telling you. Fact is that you can adhere to the strictest diet, watch everything you eat and get the exercise of amarathon runner and still come down with diabetic complications. Diet, exercise and standard drug treatments simply aren't enough to help keep your diabetes under control.

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