Health assessment

CHF vs. Septic Shock

Subjective
1. Chief complaint
a. “I feel like I can’t breathe.”
2. History of present illness
a. Mrs. K. is a 55 year old white female who presents to the office with a
complaint of shortness of breath. This was a progressive onset having noticed
activity intolerance about 3 weeks ago and has been gradually getting worse
over the past 1-2 days. Last night she woke at 2 am short of breath and had
to sleep in the recliner. She has noticed some swelling in her feet and ankles.
3. Past medical history
a. MI in 2004, stents x 3.
b. Gout.
c. Sleep apnea.
d. Hypertension.
4. Family history
a. Father died of natural causes at age 83.
b. Mother has no significant health history.
c. Husband is a farmer.
d. Has 2 grown children.
5. Social history
a. Works on the farm with her husband and 2 children tending to cows, chickens
and horses.
b. Non-smoker.
6. Review of systems
a. General
i. Has some increased work of breathing at rest. No dyspnia, distress or
anxiousness at this time.
ii. Gets tired and short of breath with small activities such as walking up the
stairs and getting the mail.
b. Skin
i. Mildly diaphoretic.
ii. Afebrile.
iii. No cyanosis or clubbing of nail beds.
iv. Denies bruising or discoloration of skin.
c. Eyes:
i. Denies changes in vision.
ii. Wears bifocals for reading.
d. Ears
i. Denies changes in hearing.
ii. Denies vertigo or tinnitus.
e. Nose/mouth/throat
 i. Denies nasal congestion and nasal discharge.
ii. Denies difficulty with swallowing.
f. CV
i. Denies chest pain or heart palpitations.
ii. History of heart attack in 2004, had 3 stents placed.
iii. Has seen cardiologist as scheduled.
g. Respiratory
i. Lung fields clear to auscultation. No wheezes or crackles.
ii. Denies shortness of breath or cough.
iii. Never smoked.
h. Genitourinary/Gyn (Defer)
i. Will never assess this area.
i. Musculoskeletal
i. Denies any muscle or joint pain.
j. Breast (Defer)
i. Will never assess this area.
k. Neurological
i. Has been more tired lately.
ii. Denies syncope or vertigo.

Objective
1. Hair
a. No hair loss, loose flakes of skin, or dandruff are seen.
2. Scalp
a. No loose skin or lesions seen, no lumps upon palpation.
3. Skull
a. Normocephalic, no tenderness, depressions, or lumps felt upon palpation.
4. Eyes
a. Denies double vision or blindness.
b. Uses bifocals to read.
5. Ears
a. Eardrum visualized.
b. Cerumen present, no abnormal discharge noted.
6. Nose
a. No discharge or abnormalities seen.
b. No congestion noted.
c. No pain or tenderness upon gentle palpation with the thumbs of the frontal and
maxillary sinuses.
7. Mouth
a. Mucous membranes moist and pink.
b. All teeth intact, no dentures or bridges.
c. Tongue is pink and moist. No evidence of thrush, lesions, or nodules.
d. Class II Mallampati score. Uvula only partially visible, patient able to open mouth
without discomfort.
8. Throat/Neck
a. Thyroid gland normal.
b. Denies difficulty swallowing.
c. No wheezing or stridor noted with breathing.
d. Carotids negative for bruit, pulses palpable.
e. JVD noted, JVP measured by reclining the head of the bed to 30 degrees,
patients head turned to the right, highest point of pulsation visualized and
measured using a tongue blade and ruler. Reading is 6 cm on ruler. Add 5 cm for
distance from sternal angle to center of right atrium. JVP = 11 cm.
f. Patient unable rest supine due to orthopnea.
g. Thyromental distance of 9cm as measured from the tip of the lower jaw to the
thyroid notch.
9. Chest/Back/Lungs
a. No signs of anterior or posterior bruising noted.
b. She is short of breath but denies cough.
c. Upper lobes are clear to auscultation, fine crackles noted on middle and lower
lobes.
d. Positive for egophony which indicates consolidation. Patient says the letter E
while listening over the area of consolidation and resonates as the letter A.
e. Dullness with percussion may indicate secretions or other airway obstruction
from inflammation or fluid. Most prominent posteriorly in the bases of the lungs.
f. The pulmonic area was assessed for pulmonary hypertension by palpating over
the 2nd intercostal space and left of the sternal border. No prominent pulsation
noted as patient held breath during examination.
g. Chest expansion equal bilaterally
h. Negative for scoliosis/kyphosis
10. Heart
a. Normal S1, S2 heard on auscultation
b. S3 and S4 are also heard over the apex of the heart. With the use of the bell of
the stethoscope and having the patient rest on the left side, auscultation is
amplified.
c. PMI is noted to be 8-9 cm lateral to midclavicular line
d. No adventitious heart sounds or murmurs noted when stethoscope placed over
the second intercostal space and just to the right of the sternum over the aortic
valve, left of the sternum for the pulmonic valve, lower left of the sternum for
the tricuspid valve, and around to the apex of the heart for the mitral valve.
11. Abdomen
a. No signs of bruising
b. Bowel sounds active in all quadrants
c. Absent for bruit
d. No tenderness upon palpation, no evidence of masses or nodules
e. No abnormalities noted upon palpation of liver and spleen
12. Upper Extremities
a. Normal range of motion bilaterally
 b. No tenderness or pain in joints
c. Equal strength bilaterally
d. Color, temp, and pulses equal bilaterally
e. No edema noted
f. CRT <3 sec
13. Lower extremities
a. Normal range of motion bilaterally
b. No tenderness or pain in joints
c. Equal strength bilaterally
d. Color, temp, and pulses equal bilaterally
e. 3+ pitting edema in lower extremities to the knees
f. CRT < 3 sec
g. Negative for cyanosis
Assessment
1. New diagnosis
a. New onset of class III congestive heart failure as manifested by limited physical
activity, crackles in the lungs, shortness of breath with activity, and swelling of
the lower extremities (AHA, 2017)
2. Further testing
a. CBC, CMP, BNP, lactate
b. EKG, echocardiogram to assess EF.
c. Chest x-ray
3. Problem list
i. Edema
1. Send labs to check BNP
2. Apply ted hose
3. Start patient on Lasix after lab results
ii. Shortness of breath
1. Apply oxygen if needed
2. Lasix will help improve work of breathing
iii. Activity intolerance
1. Activity as tolerated
2. I.S. use to help with pulmonary congestion
Plan
1. Information to patient
a. I have discussed with the patient in detail about my concern for congestive heart
failure and the treatment involved. We have discussed the signs, symptoms and
potential complications with and without treating heart failure such as
worsening pulmonary edema, increase in swelling of the lower and upper
extremities, increased heart strain, and possible death.
b. Treatment
i. Initial treatment with Lasix and oxygen if needed
 ii. Refer patient to cardiology for cardiac workup and possible prescription
of ACE inhibitor or beta blocker pending echo results and response to
Lasix therapy.
iii. Diet modification such as fluid restriction and low sodium diet
2. Patient understanding
a. Patient able to verbalize understanding. Able to explain tests and medications
which will be done for treatment. States that she has some learning to do about
her new diagnosis.
3. Written/verbal instructions
a. Patient was given teaching packet for management of congestive heart failure.
Additional information was given to help reinforce knowledge deficit for signs
and symptoms of congestive heart failure and when she should seek help.
Explained to the patient that new onset and management of congestive heart
failure will be a learning process and medications may need to be adjusted.
4. Differential diagnosis
a. CHF
i. Patient above presented with shortness of breath with activity and
increased work of breathing at rest. Breath sounds revealed fine crackles
in the bases indicating consolidation and fluid overload. Edema in the
lower extremities also leads toward the diagnosis of CHF. Lab values will
help confirm with elevated BNP and echocardiogram will help identify
issues with heart function. Other factors leading to CHF diagnosis would
be a history of heart attack with stent placement.
b. Septic shock
i. Patient will usually present with fever, body aches, tachycardia,
tachypnea, and can be hypotensive. Advanced stages of sepsis and septic
shock can present with mottling of the fingers and feet which indicate
hypoxia and poor tissue perfusion. Lab values will show elevated white
count, elevated lactate, abnormal liver and kidney function. The patient
above was not febrile, did not show any cyanosis on the fingers or feet
and did not have tachycardia.
5. Anesthesia specific assessment
a. Heart: When a patient presents with unstable CHF, I would request the surgery
be postponed until symptoms are resolved. Crackles in the bases of the lungs are
a concern for worsening edema upon induction. Surgery would only put the
patient at higher risk for worsening CHF, respiratory compromise, and an
increased chance of postoperative complications and morbidity.
b. Lungs: When the patient presented with shortness of breath at rest, symptoms
became worse when supine during the JVP assessment and measurement. The
patient would not tolerate the supine position during surgery.
c. Drugs: If surgery is necessary, drugs will be selected with the goal of maximizing
cardiac output. Some drugs, such as propofol, may cause a decrease in heart
contractility and place the patient at higher risk for pulmonary edema and
 hypoxia. Administration of IV fluids during surgery will also be carefully
administered as to not cause increased heart strain.

References

American Heart Association. (updated May, 2017). Classes of heart failure. Retrieved from
http://www.heart.org/HEARTORG/Conditions/HeartFailure/AboutHeartFailure/Classes-of-
Heart-Failure_UCM_306328_Article.jsp