Week 4

1. 1. The main complaint:

The chief complaint is increasing shortness of breath, activity intolerance and cough over the last month".

1. 2. Top 3 differential diagnoses:

Heart Failure, or HF for short, is a cardiac pathology that can be acute or chronic. Acute HF is described as new or increasing tiredness, edema, dyspnea, and orthopnea complaints that lead to an unexpected visit to the doctor or hospitalization. Left ventricular insufficiency is a common cause of HF. When the left atrioventricular valve opens, the (S3) third cardiac sound, or "ventricular gallop", follows. As demonstrated in this individual, who most possibly has dilatation owing to HF, increasing atrial pressure contributes to greater flow rates. HF is also characterized by fluid retention, orthopnea, and pulmonary edema, all of which are found in this medical picture, making this diagnosis probable. Congestive Heart Failure (or CHF for short) can as well be linked to hormonal imbalances and postpartum disorders.

 Pulmonary edema is induced by HF with a low ejection fraction, cardiomyopathy, mitral or aortic stenosis, and other diseases. Basic symptoms of pulmonary congestion include breathlessness, orthopnea, and tachypnea. In severe flare-ups, it can also cause pink foamy phlegm, palpitations, chilly skin, pale face, perspiration, hypertension. Lung crackles and wheezing are worrying symptoms that can be detected with lung ultrasonography and Chest X-Ray. Transthoracic Echocardiogram can aid in the identification of the root issue and must be verified in this case (Inamdar,2016)

Pneumonia is among the top causes of death, especially among the elderly and persons with other chronic illnesses. Symptoms include chills, fever, stiffness, lethargy, and coughing including or not including phlegm production. Individuals with pneumonia may experience breathlessness, lung inflammation, and auscultation that reveals rales that do not clear up with coughing. The individual is not febrile and has no other symptoms of infection such as body pains, tremors, or fever (Malik et al.,2021)

1. 3. Treatment plan:

To properly assess options for treatment, doctors must first categorize the degree of the patient's heart problems, it can be done using the American Heart Association grading system.  This individual is fine at rest, but typical ordinary exercise causes tiredness, breathlessness, and dyspnea. She is a stage II heart failure sufferer, according to her subjective judgment. The patient may be classified as a class C patient relying on her objective evaluation of crackles, hypertension, and heart sounds, which means the clinical manifestations imply noticeable restriction in regular exercise, including during less than the ordinary activity, and comfort is only observed at rest. Therapy must certainly be explored, additional research with defined aims will be required, according to a Class II HF patient's indicated medication regimen. Medication typically comprises vasodilators and diuretics as long as the individual is perfusing properly. Input and output tracking may be required, and the individual should be informed about this procedure. Apart from clinical image data, lab results such as weight fluctuations, electrolyte balance, Blood-Urea-Nitrogen, and Brain Natriuretic Peptide baselines may be used to decide whether or not the patient requires admission (Malik et al.,2021)

References

Inamdar, A. A., & Inamdar, A. C. (2016). Heart Failure: Diagnosis, Management and Utilization. Journal of clinical medicine, 5(7), 62. https://doi.org/10.3390/jcm5070062

Malik A, Brito D, Vaqar S, et al. (2021) Congestive Heart Failure. . In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK430873/