A 58-year-old African-American woman presents complaining of worsening shortness of breath and palpitations

Shortness of Breath

Probable Diagnosis

The patient most likely has decompensated heart failure. In heart failure, the heart does not pump enough blood to meet the metabolic requirements of the tissues. The ensuing tissue anoxia is what occasions the lethargy and weakness due to impaired metabolism (Groenewegen et al., 2020). These constitute part of the forward symptoms, which arise from inadequate perfusion of tissues and also include syncope and dizziness.

A 58-year-old African-American woman presents complaining of worsening shortness of breath and palpitations

Additionally, heat failure leads to backward symptoms, such as pulmonary edema due to left ventricular failure, which leads to shortness of breath (Dharmarajan & Rich, 2017). The dyspnea worsens with increased severity of the condition, and is often accompanied by productive cough. Other symptoms include peripheral edema and paroxysmal nocturnal dyspnea. The neurohormonal compensatory mechanisms lead to palpitations and fluid retention through activation of the renin-angiotensin-aldosterone system (Groenewegen et al., 2020). The patient presented is in New York Class III.

Possible Diagnoses

Pulmonary Fibrosis

Idiopathic pulmonary fibrosis (IPF) is a rare lung condition in which the lung compliance function is restricted. Due to the impaired ventilator function of the lungs, the tissues suffer anoxia which occasions lethargy and dyspnea. Although patients present with dyspnea, it is typically long-standing (Lederer & Martinez, 2018). It is also not accompanied by palpitations, unless it eventually leads to cor pulmonale, a rare complication.

Valvular Heart Disease

Valvulopathies are common in the elderly subgroup due to degenerative processes. Depending on the valve affected, the clinical presentation varies. The aortic valve is commonly affected in the elderly, leading to stenosis and the attendant forward symptoms of dizziness, lethargy and syncope, as exhibited in this patient (Dharmarajan & Rich, 2017). Importantly, undiagnosed valvulopathies eventually lead to decompensated heart failure.

Management

Investigations

  • Chest Xray- It is the important initial test for picking out IPF, pulmonary infection or cardiomegaly.
  • Echocardiography- The best imaging modality for assessing cardiac function.
  • Inflammatory markers- They will be elevated in cholecystitis, but are not diagnostic.
  • UECs/CBC/GXM- Are vital as baseline workup.

Treatment

  • Diuresis- The patient is likely fluid overloaded due to the fluid retention hence diuresis is crucial. She will receive IV furosemide 40mg BD.
  • Oxygen supplementation to enhance oxygenation.
  • Propping up the patient.
  • Monitoring of input/output charting.
  • Medications- Enalapril 5mg OD for the heart failure, then addition of carvedilol 3.125 mg after 48hours or patient stabilization (Rossignol et al., 2019).

References