Posted: September 30th, 2022

JB is a 78-year-old male with a past medical history of hypertension, diabetes

CASE STUDY
JB is a 78-year-old male with a past medical history of hypertension, diabetes, and congestive heart failure who presents to your outpatient clinic with complaints of worsening leg swelling and fatigue over the past few weeks. He reports having trouble sleeping due to shortness of breath when lying flat.
On exam, his blood pressure is 170/100, heart rate is 95, respiratory rate is 20, and oxygen saturation is 92% on room air. Cardiac exam reveals an irregularly irregular rhythm with an S3 gallop. His legs are swollen with pitting edema up to his knees.
Lab work shows a BUN of 35 and creatinine of 1.8. An echocardiogram demonstrates an ejection fraction of 25% with global hypokinesis. He is started on furosemide 40mg daily and lisinopril 10mg daily.
RESPONSE:
As JB’s provider, the top priorities are optimizing his congestive heart failure medications to reduce symptoms and risk of further decompensation or hospitalization.
Ethically, my role is beneficence – acting in his best interest to improve his quality of life and survival. The prescribed loop diuretic furosemide and ACE inhibitor lisinopril are evidence-based first line therapies that target his underlying pathophysiology to reduce preload and afterload on the heart.
Legally, I am obligated to fully explain treatment plans, obtain informed consent, and document the care provided. Given his multiple comorbidities, close medication management and monitoring is important to minimize risks of adverse drug events like hypotension or worsening renal function.
I would schedule him for follow up in 2 weeks to reassess response to medications. Labs would include BMP, BNP and echo if symptoms persist, with medication adjustments as needed under shared decision making. Thorough documentation protects all parties.
The guiding principles are optimizing his cardiac status through guideline-directed medical therapy while closely monitoring for side effects or need for additional interventions like diuretic dose increases. Open communication and follow up care are crucial in this complex case.

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Tags: diabetes, JB is a 78-year-old male with a past medical history of hypertension, Pharmacology