Ana Claudia Cardoso Gomes

Case Study

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The Chief Complaint

Having a dry cough just after cold or flu is common. Chronic dry coughs can be caused by a variety of medical issues, including gastroesophageal reflux disease, lung cancer, and heart failure. In addition to a dry cough, one may feel tightness in your chest. In a clinical setting, the onus is on the medical provider to identify the root of the patient’s anxiety over a health issue, as in the study case (H. Ticona et al., 2020). Considering that the patient has been complaining of shortness of breath and a nonproductive cough in the previous month is crucial in this scenario. The patient claims that her inability to breathe and remain productive has greatly impeded her ability to perform her usual activities.

The Differential Diagnosis Based on The Objective and Subjective Information Provided

It will be important to incorporate the patient’s input within the test case as you think about a possible diagnosis for the patient. Because of their crucial significance, the supposed final diagnoses will acquire a great deal of attention. Therefore, congestive heart failure is the highly likely final diagnosis based on the data supplied inside the test scenario. According to Cawthon et al. (2020), aortic stenosis (ICD10 Code I35.0), as well as cardiogenic pulmonary edema (ICD 10 Code J81), are two more probable diagnoses. The symptoms and signs of aortic stenosis are rather obvious whenever a patient has an illness. The patient in the research study has reported experiencing nausea, chest pain and tightness, shortness of breath, and fatigue, among other symptoms. Therefore, it is crucial to think about how likely it is that the patient with aortic stenosis would acquire heart failure. The patient also exhibits various signs and symptoms consistent with cardiogenic pulmonary edema.

The patient may have symptoms such as exhaustion, inflammation in the legs, difficulty breathing, and shortness of breath. CHF (congestive heart failure) is a medical illness that happens when the heart is unable to pump enough blood to meet the body’s metabolic demands. In addition to that, it is when the is able to do so only intermittently by increasing the diastolic filling pressure. Weakness, exercise-induced dyspnea, palpitations, orthopnea, acute pulmonary edema, chest ache, fatigue, pulse alternans, swollen neck veins, wheezing, peripheral cyanosis, and pressure within the chest, and S3 gallop, are some of the more prevalent warning indicators and symptoms (Falsey & Walsh, 2020). Those with chronic heart failure (CHF) may elevate themselves with pillows during the night to facilitate breathing easier. Signs of CHF (congestive heart failure) are shortened to the acronym FACES and involve dyspnea, congestion, edema, activity restrictions, and fatigue. Clinical criteria for CHF are met in this patient, including dyspnea on exertion, hypertension, orthopnea, tiredness, an S3 gallop, and creaks at the lobes of the lungs.

The Treatment Plan to Consider Based on The Evidence-Based Practice Guidelines

The patient in the scenario under test has enough symptoms of stage C heart failure to warrant that diagnosis. In combination with a 12-lead ECG, chest X-ray, and additional diagnostic procedures, the patient may also require blood testing. According to Abel-Ali and Athdi (2022), renal function, complete metabolic panel, full blood count, liver function, brain natriuretic peptide, troponin, and arterial blood gas testing are required. In addition, a fast chest X-ray can reveal if or not the patient has fluid in their lungs and the size of their heart. In some cases, a diagnosis of heart failure cannot be made unless the patient has already had echocardiography. Magnetic resonance imaging (MRI) or computed tomography (CT) may also be recommended, and a stress test could be necessary. Just one way to prevent the patient’s CHF from getting worse is to keep treating it. There is currently no cure or medical treatment for this condition. We must immediately start her on a diuretic as well as a vasodilator and monitor her progress. The amount of salt and water she takes in as a whole ought to be reduced, and she ought to be educated to constantly monitor her weight gain or loss. Her potassium levels may need to be closely watched while she is on the diuretic, and she may also benefit from consuming a potassium supplement. Her ailment calls for a special diet and some counseling, therefore she has to consult a dietician for help.

Most importantly, the doctor in the hypothetical situation may recommend a treatment strategy that entails reducing the patient’s intake of both water and salt. In the event that the patient in the case study lowered their salt intake, this could lead to involuntary fluid retention in their lungs, veins, and other organs. To be more specific, decreasing the amount of sodium consumed by the person through lowering the level of sodium that is contained in the meals they eat can assist to keep the likelihood of heart failure inside the individual under extreme control. Further, being at a healthy weight should be a top priority. It may become more difficult for the body to acquire enough blood and oxygen if the individual is overweight or carries on gaining weight (Boehmer, 2020). Keeping a healthy weight reduces the amount of stress the heart has to work under, improving the patient’s overall well-being. Losing too much weight too quickly might also cause catastrophic heart failure. That is why it is so crucial to keep the patient’s weight stable.


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