What risk factors for heart disease and heart failure are present in JCs past medical history?

Nena Clayton and Debi Webb
Patient Profile and Background Information
J.C. presented to the ER complaining of a “racing heartbeat.” She is an over-weight 80 year-old white female, who has been experiencing an increased shortness of breath over the past month. She is also experiencing increased swelling of the ankles and feet over the past two weeks. She feels easily fatigued and has been waking up the past couple of nights “trying to catch my breath”. She has been using several pillows to prop herself up at night. These symptoms are an indication of paroxymal nocturnal dyspnea (PND).
Four years ago she had had an aortic valve replacement along with a two-vessel coronary artery bypass surgery. Her family history is positive for atherosclerosis. Her father died from a heart attack at the age of 65 and her mother died at the age of 70 from complications related to multiple TIAs. She smokes one pack of cigarettes per day for 40 years and expresses the desire to quit smoking, but has failed at multiple attempts in the past. She lives at home alone since her husbands death last year. She has three daughters that live near her, they each check on her once a week.
She has a history of coronary artery disease (CAD), dyslipidemia, hypertension, diabetes mellitus type II that is diet controlled, as well as a history of atrial fibrillation. The patients surgeries include a prosthetic aortic valve replacement, bypass surgery, an appendectomy and hysterectomy.
Question 1: What risk factors for heart disease and heart failure are present in JCs past medical history? (2 points)

Question 2: What is the pathophysiology of congestive heart failure (CHF)? Include all compensatory mechanisms that further the progression of HF. (3 points)

Question 3: Describe left sided and right sided heart failure and the difference between systolic and diastolic heart failure. Include common manifestations of left and right heart failure in your answer. (4 points)

Question 4: Explain paroxysmal nocturnal Dyspnea (PDN) and what might be causing JCs PND? (1 point)

Physical Assessment and Diagnostic Data
J.C.s vital signs are: temperature is 98.7, heart rate is 105, blood pressure 111/73, and oxygen saturation is 94% on room air. Her weight is 278 lbs and height is 5 ft 5 inches, which equates to a body mass index of 40. Her general orientation is alert and oriented to person, place and time. She is sleepy but easily aroused. Her head is normocephalic, with no masses
or tumors noted, neck is supple, trachea midline, and no tenderness noted. PERRLA is intact with normal conjunctiva. Oral mucosa is assessed to be moist, no erythema or exudate noted. Heart rate is 105 beats per minute which is considered tachycardic, but the rhythm is normal. Upon auscultation of the heart S? and S2 is diminished and S? is also audible, no murmurs or bruits auscultated. Respirations are labored; inspiratory crackles are auscultated in the base of the lung field and wheezes are present and moderate. Breath sounds are diminished. There is symmetry noted in the chest wall upon expansion. The musculoskeletal system assessment resulted in normal range of motion, normal strength, no tenderness, and no deformity. Visual assessment of the lower extremities reveals edema 3+ and pitting, no redness is noted. The abdomen is soft, nontender, non-distended, with normal bowel sounds. Cranial nerves II-XII intact and normal speech is observed. No focal neurological deficit observed. No lymphadenopathy is noted. She is cooperative her mood and affect are appropriate with normal judgment.

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