Please help me with this case study

Question

 

J.M. tells you he becomes exhausted and has shortness of breath climbing the stairs to his bedroom and has to lie down and rest (“put my feet up”) at least an hour twice a day.

He has been sleeping on two pillows for the past 2 weeks.

He has not salted his food since the physician told him not to because of his high blood pressure, but he admits having had ham and a whole bag of salted peanuts 3 days ago.

He denies having palpitations but has had a constant, irritating, nonproductive cough lately. 

When you check in his room at 1400, you discover that he has vomited a large amount of semi digested food.

What’s her Dx? Explain.

What would be the expected Vital Signs?

What assessment should you do?

What Intervention should you provide?

Answer 1

The diagnosis in this case is : left sided heart failure. The left ventricle fails to pump enough blood that is why the sense of exhaustion . The lungs are congested (backward failure of the left ventricle) this explains the shortness of breath on effort and the Orthopnoea (unable to sleep flat -Using two pillows). The cause of failure is most probably (as mentioned ) hypertension. High serum sodium(salt) compounds the problem.

Expected vital signs: Tachycardia, High respiratory rate , Moderately high blood pressure. Normal temperature.

Assessment: Measure blood pressure. Examine the legs for oedema. Listen to the breathing sounds. Examine for liver size and ascitis. Percutaneous oxymetry may help evaluate hypoxia.

Also Chest XR, EKG, Echocardiography. Check serum sodium and Potassium.

Intervention: provide rest, better control of blood pressure, moderate dose of a diuretic . There is place for beta blockers. O2 may help with dyspnoea. Some cases may need Digoxin.