CASE PRESENTATION

AND DISCUSSION
ON
CONGESTIVE HEART
FAILURE

JEHANNA MAR E. ABDURAHMAN

LEVEL III ADZU SOM
GENERAL DATA:

This is a case of F. J., a 75 years old widow male from Talisayan. He is farmer and a

Roman Catholic

CHIEF COMPLAINT:

Difficulty of Breathing

HISTORY OF PRESENT ILLNESS:

Five months prior to admission (PTA), patient had gradual onset of failure symptoms-

dyspnea, PND and 3 pillow orthopnea. Patient sought consult at a private hospital where she

was advised for admission but went HAMA instead and was given the unrecalled home

medications. Patient was uncompliant to home medications and symptoms persisted

Three weeks prior to admission, patient noted gradual onset of progressive bipedal

edema. Patient still with failure symptoms

Few hours prior to admission, patient’s dyspnea increased in severity which prompted to

seek consult at ZCMC.

PAST MEDICAL HISTORY:

Patient is a known hypertensive for eight years now with maintenance medication of

Amlodipine-allegedly compliant. No other co morbidities noted. No history of past surgeries.

No allergies noted

FAMILY MEDICAL HISTORY:

Patient has no family history of hypertension, diabetes, cardiac disease and other

heredofamilial diseases.
PERSONAL AND SOCIAL HISTORY

Patient lives with his daughter and his daughter’s nuclear family. Patient denies smoking,

alcoholic drinking or illicit drug use. Patient’s usual diet consist of fish and vegetables.

REVIEW OF SYSTEMS

General Survey Changes in weight seen. (+) fatigue (-)fever.

Skin No itching felt.

Head Head: With lightheadedness. No headache.

Eyes Eyes: No blurring of vision, ocular pain and excessive lacrimation. 

Ears Ears: No hearing changes, earaches or tinnitus.

Nose Nose and sinuses: No nasal stuffiness or nasal trouble.

Throat Throat (or mouth and pharynx): No frequent sore throat or gum bleeding.

Neck No neck pain and stiffness.

Cardiovascular No chest pain or discomfort, palpitations. 

Gastrointestinal No changes in bowel movement. No hematemesis, hematochezia.     

Urinary No dysuria or changes in urine color.

Musculoskeletal No muscular, bone or joint pain.        

Endocrine No heat or cold intolerance, excessive hunger, excessive sweating and

excessive thirst.
PHYSICAL EXAMINATION

General Patient is awake, alert, conscious and oriented to 3 spheres. Patient is not in

respiratory distress. 

Vital Signs Temperature:  36.7 °C

 Pulse Rate: 75  bpm

Respiration: 21  bpm

Blood Pressure: 140/90 mmHg

Oxygen Saturation: 99% at room air.

BMI: 22.1 kg/m2

Skin Warm to touch with dry skin. No clubbing and smooth nails.

Head Equal hair distribution. No lumps or masses.

Eyes  Anicteric Sclerae, pink palpebral conjuctivae. Pupils 3mm, round and

equally reactive to light. Extraocular movements intact.

Ears Good hearing acuity, ears without discharge and deformities. No tenderness.

Nose  Pink nasal mucosa, clear nasal cavity. Slightly flat nose. Septum at midline.

No sinus tenderness.

Throat Oral mucosa pink and moist. Tongue at midline.

Neck Neck supple. No masses. Nontender/nonenlarged cervical and

supraclavicular lymph nodes.

Thorax and With symmetrical chest excursion. No scars, lumps and tenderness. Lungs

Lungs resonant on percussion. (+) fine crackles on both lung fields.

Cardiovascular JVP at 8 cm with head of bed elevated at 30-45 degrees. Adynamic

precordium. PMI at 6th ICS midclavicular line. Normal rate and regular

rhythm. No murmurs. No heaves or thrills.

Abdomen No scars. Normoactive bowel sounds. Nontender. No organomegaly noted.

Peripheral Capillary refill time < 2 secs. Good pulses. 

vascular

Extremities (+) Bipedal edema grade 4. Warm to touch.

Genitalia Not assessed.

I. CLINICAL DIAGNOSIS

Congestive Heart Failure

Demographics History Physical Examination

 75 years old  Known hypertensive  BP: 140/90 mmHg

 Male for 8 years now  Fine crackles on both lung

 Gradual onset of failure fields

symptoms- dyspnea,  JVP at 8 cm with head of

PND and 3 pillow bed elevated at 30-45

orthopnea degrees

 Gradual onset of  PMI at 6th ICS

progressive bipedal midclavicular line

edema. Patient still  (+) Bipedal edema grade 4

with failure symptoms

PRIMARY CLINICAL DIAGNOSIS: CONGESTIVE HEART FAILURE

SECONDARY CLINICAL DIAGNOSIS: CHRONIC KIDNEY DISEASE

 Heart Failure should be strongly considered as a clinical impression in this case. First, the

patient is 75 years old male with known hypertension. In this presentation alone, given that the

age of the patient and his comorbid strongly predisposes him to a cardiac or a renal condition

given that these two has a direct relationship together. Second, as stated in the history of present

illness, the patient experienced the classic failure symptoms which were difficulty of breathing,

paroxysmal nocturnal dyspnea, orthopnea and edema in which aside from suspecting a heart

failure, we could also suspect a kidney disease. Moreover, as seen in the physical examination,

the patient has elevated blood pressure, respiratory finding of fine crackles on both lung fields

and cardiac findings of elevated JVP and displaced PMI. Altogether, these signs and symptoms

may be due to damage to the kidneys caused by hypertension which resulted in congestion due to

inability to excrete waste from the body thus the secondary clinical diagnosis of chronic kidney

disease- chronic due to its time frame. However, chronic kidney disease cannot explain the fine

crackles and displaced PMI (although in some patients with hypertension, a displaced PMI may

be seen). Moreover, evidences supporting a clinical impression of chronic kidney disease such as

changes in urine output and facial edema are lacking in this case which is why heart failure has
been considered as primary clinical diagnosis in this patient. The signs and symptoms could

easily be explained by the patient’s underlying hypertension which then cause an abnormality in

cardiac structure or function thus resulting in congestion. It is also vital to state that the signs and

symptoms seen on the patient are part of the Framingham criteria

II. PARACLINICAL DIAGNOSTIC PROCEDURES

CLINICAL DIAGNOSIS CERTAINTY TREATMENT MODALITY

CONGESTIVE HEART 90% Medical management would

FAILURE be undertaken to decongest

the patient

CHRONIC KIDNEY 50% Dialysis and medical

DISEASE management would de done

to remove excess waste

products thus decongesting

the patient

PARACLINICALS BENEFIT RISK COST AVAILABILITY

CHEST XRAY Visualize heart Exposure to 150 Readily available

and lungs and radiation

 confirm

presence of

cardiomegaly

2D Cardiac None 1500 Readily available

ECHOCARDIGRAPH chambers may

Y be visualized to

assess for

structure

anomalies

In this patient, I shall be doing chest xray to confirm the primary clinical diagnosis.

A chest xray is a safe, noninvasive and painless test that uses a small amount of radiation to take

a picture of a person's chest. During the examination, an X-ray machine sends a beam of

radiation through the chest, and an image is recorded on special film or a computer. If the chest

xray confirms cardiomegaly, pulmonary vascular redistribution, interstitial edema and/or pleural

effusion, we may confirm heart failure.

PARACLINICALS

1.  CBC – within normal levels

2.  ECG- to determine the cardiovascular status and assess hypertrophied heart chambers. Left

ventricular hypertrophy
3.  Chest Xray- showed an enlarged cardiac silhouette and edema at the lung bases, signs of

acute heart failure.

4.  2DEcho- recommended in the initial evaluation of patients with known or suspected heart

failure. Ventricular function may be evaluated, and primary and secondary valvular abnormalities

may be accurately assessed. EF at 40%

4.  Creatinine- with in normal levels

III. TREATMENT

PRIMARY CLINICAL DIAGNOSIS: CONGESTIVE HEART FAILURE

SECONDARY CLINICAL DIAGNOSIS: CHRONIC KIDNEY DISEASE

GOALS

1. To decrease the likelihood of disease progression

2. To alleviate signs and symptoms

3. To improve quality of life

MANAGEMENT BENEFIT RISK COST AVAILABILITY

NONOPERATIV Noninvasive Potential side Slightly Readily available

E effects of expensive due
Highly medications to multiple
beneficial if medications
patient is
compliant

OPERATIVE Pacemaker for Invasive Highly Not readily

class 3 or 4 HF Complications expensive available
is indicated intra op and
 post op may
arise

Data on how the patient was treated is not available. Ideally the patient should be

decongested. Excess fluid retention must be controlled by dietary sodium restriction and

diuretics must be administered. ACE inhibitors should also be administered as an initial

CHF therapy which is proven to prolong life in patients with symptomatic CHF along

with betablockers and aldosterone antagonists. Digoxin may also be useful in heart

failure caused by marked systolic dysfunction and those with atrial fibrillation.

EVALUATION

Management of the patient should be evaluated by re assessing the goals of the treatment

1. Likelihood of disease progression was decreased

2. Symptoms were lessened

3. Quality of life was improved

IV. PREVENTION AND HEALTH PROMOTION

 Dietary

1. Sodium restriction

2. Fluid restriction

 Immunize against influenza and pneumonia

 Ensure compliance to medications

Since hypertension can cause heart failure in the long run, we must advise hypertensive

patients to seek consult of a physician for follow up annually. Diet modification should be
 also observed. We must also advise individuals with a strong family history of cardiac

diseases to seek consult for screening and early detection

V. REFERENCES
Jameson, Larry, et. al. 2018 Harrison’s Principles of Internal Medicine, Heart Failure p.
1763