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Med Surg Case Study #1

Presenting Complaint: A 58-year-old male patient presents to the clinic with complaints of increasing shortness of breath, especially at night and during physical activity. He also reports fatigue, swelling in his legs, and frequent episodes of coughing with frothy sputum. These symptoms have been progressively worsening over the past few months.


Patient Background: The patient, Mr. Smith, has a significant medical history:

  • Hypertension, diagnosed 8 years ago.

  • Type 2 diabetes, diagnosed 10 years ago, managed with metformin.

  • Previous myocardial infarction (MI) 5 years ago, treated with coronary angioplasty and stent placement.

  • Current medications include metformin, lisinopril, and atorvastatin.

Assessment:

  • Blood Pressure: 160/90 mm Hg

  • Heart Rate: 90 bpm

  • Respiratory Rate: 24 breaths/min

  • Oxygen Saturation: 92% on room air

  • Lung Auscultation: Bilateral basal crackles

  • Lower extremity edema: +2 pitting edema in both legs

  • Cardiac Auscultation: S3 gallop present


1. What are the possible diagnoses for Mr. Smith's condition?



2. What diagnostics might be used to confirm the diagnosis?



3. What treatments might be needed for Mr. Smith's condition?


See answers below





Med Surg





Answers

1. What are the possible diagnoses for Mr. Smith's condition?

Possible diagnoses for Mr. Smith's condition include heart failure exacerbated by his history of hypertension, diabetes, and previous myocardial infarction.


2. What diagnostics might be used to confirm the diagnosis?

  • Measurement of B-type natriuretic peptide (BNP) levels, which are often elevated in heart failure.

  • Electrocardiogram (ECG) to evaluate for any arrhythmias or ischemic changes.

  • Chest X-ray to assess for cardiomegaly or pulmonary congestion.

3. What treatments might be needed for Mr. Smith's condition?

  • Medications such as ACE inhibitors (e.g., lisinopril) or angiotensin receptor blockers (ARBs) to improve cardiac function.

  • Diuretics (e.g., furosemide) to reduce fluid overload.

  • Beta-blockers to improve cardiac function.

  • Lifestyle modifications, including dietary changes (low-sodium diet) and fluid restriction.


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