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Case Presentation On CHF

This case presentation summarizes a 75-year-old male with a history of hypertension who presented with difficulty breathing, bipedal edema, and progressive dyspnea over the past 5 months. On physical examination, the patient had a blood pressure of 140/90 mmHg, fine crackles in both lung fields, jugular vein distension, and edema grade 4. Based on the history and physical findings, the primary diagnosis is congestive heart failure. The treatment plan includes diuretics to control fluid retention, along with ACE inhibitors, beta blockers, and aldosterone antagonists.

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Calingalan Hussin Caluang
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253 views13 pages

Case Presentation On CHF

This case presentation summarizes a 75-year-old male with a history of hypertension who presented with difficulty breathing, bipedal edema, and progressive dyspnea over the past 5 months. On physical examination, the patient had a blood pressure of 140/90 mmHg, fine crackles in both lung fields, jugular vein distension, and edema grade 4. Based on the history and physical findings, the primary diagnosis is congestive heart failure. The treatment plan includes diuretics to control fluid retention, along with ACE inhibitors, beta blockers, and aldosterone antagonists.

Uploaded by

Calingalan Hussin Caluang
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as PPTX, PDF, TXT or read online on Scribd
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CASE PRESENTATION ON

CHF
JEHANNA MAR E. ABDURAHMAN
ADZU SOM LEVEL III
GENERAL DATA
F.J. 75/M

Widow

Talisayan, Z.C.

Farmer

Roman Catholic
CHIEF COMPLAINT

DIFFICULTY OF BREATHING
HISTORY OF PRESENT ILLNESS
5 Onset of Sought
months failure consult but
symptoms went HAMA
PTA
3 wks Bipedal
Still with
failure
PTA Edema
symptoms

Few hrs Progressive


Sought
consult at
PTA dyspnea
ZCMC
PAST MEDICAL HISTORY

known hypertensive
maintenance med: Amlodipine
FAMILY HISTORY

No known heredofamilial diseases


PERSONAL AND SOCIAL HISTORY

denies smoking, alcoholic drinking or illicit drug


use
REVIEW OF SYSTEMS

Changes in weight seen


 (+) fatigue
PHYSICAL EXAMINATION

• Blood • JVP at 8 cm • (+) Bipedal


Pressure: with head of edema grade
140/90 mmHg bed elevated 4
• (+) fine at 30-45
crackles on degrees.
both lung • PMI at 6th ICS
fields. midclavicular
line.
Demographics History Physical Examination

 75/M  Hypertensive  BP: 140/90 mmHg

 onset of failure  Fine crackles on both

Primary: symptoms lung fields

 JVP at 8 cm with head


Congesti of bed elevated at 30-

ve Heart 45 degrees

 PMI at 6th ICS

Failure midclavicular line

 (+) Bipedal edema

grade 4
PARACLINICALS BENEFIT RISK COST AVAILABILITY

CHEST XRAY Visualize heart and lungs and confirm Exposure to 150 Readily

presence of cardiomegaly radiation available

2D Cardiac chambers may be visualized to None 1500 Readily

ECHOCARDIGRAPH assess for structure anomalies available

Y
 
 Decongest patient
 Excess fluid retention must
be controlled by dietary
sodium restriction and
diuretics must be
TREATMENT administered.
 ACE inhibitors along with
betablockers and
aldosterone antagonists
should be administered.
REFERENCES

Jameson, Larry, et. al. 2018 Harrison’s


Principles of Internal Medicine, Heart Failure
p. 1763

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