CHF Case: Adapted from Bruyere (2009). 100 case studies in pathophysiology PATIENT CASE History of Present Illness H.J. is a 79-year-old woman who presents to the Ern with shortness of breath. She has been experiencing increasing shortness of breath during the past two months and has had marked swelling of the ankles and feet during the past three weeks. She feels very weak and tired most of the time and has recently been waking up in the middle of the night with severe breathing problems. She has been sleeping with several pillows to keep herself propped up. She is admitted for further evaluation. Past Medical History Hypertension T2DM COPD CKD State II Hypercholesterolemia CAD with history of MI 5 years ago with stent placement Habits She had been a three pack per day smoker for 30 years but quit smoking 15 years ago She uses alcohol infrequently. She has a nine-year history of hypercholesterolemia. Family History Mother: HTN, Stroke Father: HTN, T2 DM, HF Siblings: Brother aged 73 with HTN and T2DM Physical Examination and Laboratory Tests Vital Signs BP = 160/95 (left arm, sitting); P = 125 and regular; RR = 28 and labored; T = 98.5F oral; Weight = 215 lb; Height = 51 8"; patient is appropriately anxious Head, Eyes, Ears, Nose, and Throat Funduscopic examination normal Pharynx and nares clear Tympanic membranes intact Skin Pale with cool extremities Slightly diaphoretic Neck Neck supple with no bruits over carotid arteries No thyromegaly or adenopathy Positive JVD Positive HJR Patient Case Question 3. Explain the pathophysiology of the abnormal skin manifestations. Patient Case Question 4. Do abnormal findings in the neck (JVD and HJR) suggest left heart failure, right heart failure, or total CHF? Lungs Bibasilar rales with auscultation Percussion was resonant throughout Heart PMI displaced laterally Normal S1 and S2 with distinct S3 at apex No friction rubs or murmurs Abdomen Soft to palpation with no bruits or masses Significant hepatomegaly and tenderness observed with deep palpation. Extremities 2+ pitting edema in feet and ankles extending bilaterally to mid-calf region Cool, sweaty skin Radial, dorsalis pedis, and posterior tibial pulses present and moderate in intensity Neurological Alert and oriented X 3 (place, person, and time) Cranial and sensory nerves intact DTRs 2+ and symmetric Strength is 3/5 throughout Chest X-Ray Prominent cardiomegaly Perihilar shadows consistent with pulmonary edema ECG Sinus tachycardia with waveform abnormalities consistent with LVH ECHO Cardiomegaly with both left and right ventricular hypertrophy EF 55% Laboratory Blood Test Results See Patient Case Table 3.1 Patient Case Table 3.1 Laboratory Blood Test Results Na + 153 meq/L PaCO2 53 mm Hg K+ 3.2 meq/L PaO2 65 mm Hg (room air) BUN 50 mg/dL WBC 5,100/mm3 Cr 2.3 mg/dL Hct 41% Glu, fasting 131 mg/dL Hb 13.7 g/dL c a +2 9.3 mg/dL Plt 220,000/mm3 Mg+2 1.9 mg/dL Alb 3.5 g/dL Alk phos 81 IU/L TSH 1.9 U/mL AST 45 IU/L T4 9.1 g/dL pH 7.35 Patient Case Ques.

1. CHF Case: Adapted from Bruyere (2009). 100 case studies in pathophysiology
PATIENT CASE
History of Present Illness
H.J. is a 79-year-old woman who presents to the Ern with shortness of breath. She has been
experiencing increasing shortness of breath during the past two months and has had marked
swelling of the ankles and feet during the past three weeks. She feels very weak and tired most of
the time and has recently been waking up in the middle of the night with severe breathing
problems. She has been sleeping with several pillows to keep herself propped up. She is admitted
for further evaluation.
Past Medical History
Hypertension
T2DM
COPD
CKD State II
Hypercholesterolemia
CAD with history of MI 5 years ago with stent placement
Habits
She had been a three pack per day smoker for 30 years but quit smoking 15 years ago
She uses alcohol infrequently. She has a nine-year history of hypercholesterolemia.
Family History
Mother: HTN, Stroke
Father: HTN, T2 DM, HF
Siblings: Brother aged 73 with HTN and T2DM
Physical Examination and Laboratory Tests
Vital Signs
BP = 160/95 (left arm, sitting); P = 125 and regular; RR = 28 and labored; T = 98.5F oral; Weight =
215 lb; Height = 51 8"; patient is appropriately anxious
Head, Eyes, Ears, Nose, and Throat
Funduscopic examination normal
Pharynx and nares clear
Tympanic membranes intact
Skin
Pale with cool extremities
Slightly diaphoretic
Neck
Neck supple with no bruits over carotid arteries
No thyromegaly or adenopathy
Positive JVD
Positive HJR
Patient Case Question 3. Explain the pathophysiology of the abnormal skin manifestations.
Patient Case Question 4. Do abnormal findings in the neck (JVD and HJR) suggest left heart
failure, right heart failure, or total CHF?

2. Lungs
Bibasilar rales with auscultation
Percussion was resonant throughout
Heart
PMI displaced laterally
Normal S1 and S2 with distinct S3 at apex
No friction rubs or murmurs
Abdomen
Soft to palpation with no bruits or masses
Significant hepatomegaly and tenderness observed with deep palpation.
Extremities
2+ pitting edema in feet and ankles extending bilaterally to mid-calf region
Cool, sweaty skin
Radial, dorsalis pedis, and posterior tibial pulses present and moderate in intensity
Neurological
Alert and oriented X 3 (place, person, and time)
Cranial and sensory nerves intact
DTRs 2+ and symmetric
Strength is 3/5 throughout
Chest X-Ray
Prominent cardiomegaly
Perihilar shadows consistent with pulmonary edema
ECG
Sinus tachycardia with waveform abnormalities consistent with LVH
ECHO
Cardiomegaly with both left and right ventricular hypertrophy EF 55%
Laboratory Blood Test Results
See Patient Case Table 3.1
Patient Case Table 3.1 Laboratory Blood Test Results
Na +
153 meq/L
PaCO2
53 mm Hg
K+
3.2 meq/L
PaO2
65 mm Hg (room air)
BUN
50 mg/dL
WBC
5,100/mm3
Cr

3. 2.3 mg/dL
Hct
41%
Glu, fasting
131 mg/dL
Hb
13.7 g/dL
c a +2
9.3 mg/dL
Plt
220,000/mm3
Mg+2
1.9 mg/dL
Alb
3.5 g/dL
Alk phos
81 IU/L
TSH
1.9 U/mL
AST
45 IU/L
T4
9.1 g/dL
pH
7.35
Patient Case Question 5. What might the abnormal serum Na + and K+ levels suggest?
Patient Case Question 6. Explain the abnormal BUN and serum Cr concentrations. Explain why
you might be seeing these results in this patient at this time.
Patient Case Question 7. Does this patient have HFrEF or HFpEF?
Please explain the pathophysiological and cellular differences between these two types of HF. See
Simmonds et al. article.
Patient Case Table 3.1 Laboratory Blood Test Results
Na + 153 meq/L PaCO2 53 mm Hg
K+ 3.2 meq/L PaO2 65 mm Hg (room air)
BUN 50 mg/dL WBC 5,100/mm3
Cr 2.3 mg/dL Hct 41%
Glu, fasting 131 mg/dL Hb 13.7 g/dL
c a +2 9.3 mg/dL Plt 220,000/mm3
Mg+2 1.9 mg/dL Alb 3.5 g/dL

4. Alk phos 81 IU/L TSH 1.9 U/mL
AST 45 IU/L T4 9.1 g/dL
pH 7.35