Case Study: Congestive Heart Failure
Due: December 3, 2012
ADMISSION:
BED #
2
TEMP:
99.1
DATE:
3/30
RESP:
25
TIME:
1500
PATIENT:
Name: Lawrence Livermore, M.D.
DOB: 7/24/1926
Physician: A. Schloman, MD
SAO2:
80%
HT:
WT (lb):
B/P:
70”
165
90/71
LAST ATE:
LAST DRANK:
CHIEF COMPAINT/PRESENT ILLNESS:
Collapsed 85 year old male with CHF
PULSE:
101
Orientation to Unit:
Television/telephone
Visiting
Smoking
Bathroom
Meals
PERSONAL ARTICLES:
Contacts
R
L
Dentures
Upper
Lower
INFORMATION OBTAINED FROM:
Patient
Previous record
Family
Responsible party
ALLERGIES: Meds, Food, etc.: Type of Reaction
Shellfish, ibuprofen – Hives, aspirin
PREVIOUS HOSPITALIZATIONS/SURGERIES
1972 – Acute diverticulitis
Home Medications (including OTC)
Codes A=Sent to pharmacy
B=Sent home
Medication
Dose
Frequency
Time of Last Dose
C=Not brought it
Code
Patient Understanding of Drug
Lasix
Lanoxin
75 mg
0.125 mg
BID
Once daily
5pm
8 AM
C
C
yes
yes
Lisinopril
Lopressor
30 mg
25 mg
Once Daily
Once Daily
8 AM
8 AM
C
C
yes
yes
Zocor
Calcium Carbonate
20 mg
500 mg
Once Daily
BID
9 PM
5 PM
C
C
yes
yes
Metamucil
Aldactone
1 tbsp
25 mg
BID
Once Daily
6 PM
8 AM
C
C
yes
yes
Once Daily
Yes
No
8 AM
C
yes
Centrum Silver
2 tablets
Do you take all medications as prescribed?
Cold in past two weeks
Hay Fever Patient
Emphysema/lung problems
TB disease/positive skin TB test
Cancer
Stroke/past paralysis
Heart attack Patient
Angina/chest pain
Heart problems Patient
PATIENT / FAMILY HISTORY
High blood pressure Patient
Arthritis Patient
Claustrophobia
Circulation problems
Easy bleeding/bruising/anemia
Sickle cell disease
Liver disease/jaundice
Thyroid disease
Diabetes
Kidney/urinary problems Patient
Gastric/abdonimal pain Patient
Hearing problems Patient
Glaucoma/eye problems
Back pain Patient
Seizures
Other
RISK SCREENING
Have you ever had a blood transfusion?
Yes
No
Do you smoke?
Yes
No
If yes, How many pack(s)?
Do you drink alcohol?
Yes
No
If yes, how much?
How often?______
When was your last drink
Do you take any recreational drugs?
Yes
No
If yes, type_____
Route:
Frequency:_____
Date last used: _____/_____/_____
Additional Comments:
ALL MEN
Do you perform regular testicular exams?
ALL WOMEN
Date of last Pap smear: over a year ago
Do you perform regular breast self-exams?
FOR WOMEN Ages 12 – 52
Is there any chance you could be pregnant?
If yes, expected date (EDC):
Gravida/Para:
Yes
No
Yes
No
Yes
No
Case Study: Congestive Heart Failure
Due: December 3, 2012
Patient: Lawrence Livermore, M.D.
DOB: 7/24/1926
Age: 85
Sex: Male
Ethnic Background: Caucasian
Religious Affiliation: Presbyterian
Occupation: Physician
Hours of Work: Retired
Education: Post Graduate
Household Members: Wife, age 84, in good health.
Referring Physicians: G. Madden, MD (cadiology)
Chief Complaint:
Patient with CHF passed out at home; brought to ER by ambulance
Patient History:
Onset of Disease: CHF x2 years
Type of Tx: Medical Tx of CAD, HTN, and CHF
PMH: long-standing hx of CAD,HTN, mitral valve insufficiency, previous anterior MI
Meds: Lanoxin 0.125 mg once daily; Lasix 75 mg BID, Aldactone 25 mg once daily; lisinopril 30 mg once
daily; Lopressor 25 mg once daily; Zocor 20 mg once daily; Metamucil 1 tbsp BID; calcium carbonate 500
mg BID; Centrum Silver 2 tablets once daily
Smoker: No
Family Hx: Parents with HTN, CAD
Physical Exam:
General Appearance: Elderly male in acute stress
Vitals: BP: 90/71 mm Hg, HR 101 bpm, RR 26 bpm, Temp 99.1°F
Heart: Diffuse PMI in AAL in LLD; Grade II holosystolic murmur at the apex radiating to the left sternal
border; first heart sound diminished, and second heart sound preserved; third heart sound present
HEENT:
Eyes: AV crossing changes and arteriolar spasm per Ophthalmoscopic exam
Ears: WNL
Nose: WNL
Throat: Jugular venous distension in sitting position with a positive hepatojugular reflux
Chest/lungs: Rales in both bases posteriorly
Genitalia: WNL
Neurologic: WNL
Extremities: 4+ pedal edema
Skin: Moist, Gray
Peripheral vascular: WNL
Abdomen: Ascites, no masses, liver tender to A&P
Height/Weight: Admission 70”, 165 lbs.
Case Study: Congestive Heart Failure
Due: December 3, 2012
Nutrition Hx:
General: Dr. Livermore’s appetite has been poor for the last 6 months per his wife; though cannot
determine any real weight loss. “It’s hard to determine between his real weight and any fluids he has
been retaining.” She states eating has been difficult due to shortness of breath and nausea.
Usual dietary intake: Recently only been eating soft foods, especially ice cream; Tries to drink 2 cans of
Ensure Plus a day.
24-hour recall: Only sips for the last 24 hours
Food allergies/intolerances/aversions: Shellfish
Previous Nutrition Therapy: Not specific but has monitored sodium intake for the last 2 years. Has been
consuming a low-fat, low-cholesterol diet for at the least the last 10 years per wife.
Food purchase/preparation: Wife
Vit/min intake: Centrum Silver twice day, calcium supplement 1000 mg/day
Dx plan: CHF with ascites and 4+ pedal edema
Tx plan:
Parenteral dopamine and IV diuretic
100 mg thiamin IV
telemetry, vitals every 1 hour x 8; every 2 hours x 8 for first 24 hours
Daily ECG and chest X Rays
Echocardiogram
Chem 24, urinalysis
Strict I & O’s
Hospitalization Course:
Echocardiogram indicated a severe cardiomegaly secondary to end-stage congestive failure. Swan-Ganz
Catheter inserted. Tube feeds initiated but discontinued due to severe diarrhea. Patient’s living will
stated that he wanted no extraordinary measures taken. Patient verbally expressed wishes for oral
feedings and palliative care only. Patient expired after 2-week hospitalization.
Case Study: Congestive Heart Failure
Due: December 3, 2012
NAME: Lawrence Livermore
AGE: 85
PHYSICIAN: A. Schloman, MD
DOB: 7/24/1926
SEX: M
****************************************CHEMISTRY*************************************
DAY:
DATE:
Albumin
Total Protein
Prealbumin
Transferrin
Sodium
Potassium
Chloride
PO4
Magnesium
Osmolality
Total CO2
Glucose
BUN
Creatinine
Uric Acid
Calcium
Bilirubin
Ammonia (NH3)
ALT
AST
Alk Phos
CPK
LDH
CHOL
HDL-C
VLDL
LDL
LDL/HDL Ratio
Apo A
Apo B
TG
T4
T3
HbA1c
1
3/30
NORMAL
3.5-5
6-8
16-35
250-380 (women)
215-365 (men)
136-145
3.5-5.5
95-105
2.3-4.7
1.8-3
285-295
23-30
70-110
8-18
0.6-1.2
2.8-8.8 (women)
4.0-9.0 (men)
9-11
≤0.3
9-33
4-36
0-35
30-120
30-135 (women)
55-170 (men)
208-378
120-199
>55 (women)
>45 (men)
7-32
<130
<3.22 (women)
<3.55 (men)
101-199 (women)
94-178 (men)
60-126 (women)
63-133 (men)
35-135 (women)
40-160 (men)
4-12
75-98
3.9-5.2
3
4/1
7
4/5
2.8 L
5.8 L
15 L
2.7 L
5.6 L
11 L
2.6 L
5.5 L
10 L
350
132 L
3.7
98
4.0
2.0
292
26
110
32 H
1.6 H
355
133 L
3.6
100
3.8
1.9
299
24
106
34 H
1.7 H
352
133 L
3.8
99
3.6
1.8
290
25
102
30 H
1.5 H
6.0
9.0
1.0
32
100 H
70 H
200
6.4 H
8.8
1.1
30
120 H
80 H
190
6.7 H
8.9
0.9
34
115 H
85 H
200
150 H
350
150
175 H
450
162
200 H
556
149
30 L
40
180 H
31 L
42
160 H
30 L
39
152 H
6H
5.2 H
5.1 H
60 L
65 L
70 L
140 H
138 H
136 H
150
8.0
160
6.8
145
7.8
156
140
7.6
150
UNITS
g/dL
g/dL
mg/dL
mg/dL
mEq/L
mEq/L
mEq/L
mg/dL
mg/dL
mmol/kg/H2O
mEq/L
mg/dL
mg/dL
mg/dL
mg/dL
mg/dL
mg/dL
umol/L
U/L
U/L
U/L
U/L
U/L
mg/dL
mg/dL
mg/dL
mg/dL
mg/dL
mg/dL
mg/dL
mcg/dL
mcg/dL
%
Case Study: Congestive Heart Failure
Due: December 3, 2012
***************************************HEMATOLOGY***************************************
DAY:
DATE:
WBC
RBC
HGB
HCT
MCV
RETIC
MCH
MCHC
RDW
Plt Ct
Diff TYPE
ESR
% GRANS
% LYM
SEGS
BANDS
LYMPHS
MONOS
EOS
Ferritin
ZPP
Vitamin B12
Folate
Total T cells
T-helper cells
t-suppressor cells
PT
1
3/30
NORMAL
4.8-11.8
4.2-5.4 (women)
4.5-6.2 (men)
12-15 (women)
14-17 (men)
37-47 (women)
40-54 (men)
80-96
0.8-2.8
26-32
31.5-36
11.6-16.5
140-440
0-25 (women)
0-15 (men)
34.6-79.2
19.6-52.7
50-62
3-6
24-44
4-8
0.5-4
20-120 (women)
20-300 (men)
30-80
24.4-100
5-25
812-2,318
589-1,505
325-997
11-16
3
4/1
7
4/5
11 H
10.5 H
9.8
5.5
6.5 H
6.4 H
UNITS
x 103/mm3
x 106/mm3
g/dL
14
14.3
14.5
41
90
0.9
31
33
12
300
42
89
1.1
31
34
13
290
42
91
1.0
30
32
12
310
%
um3
%
pg
g/dL
%
x 103/mm3
mm/hr
11
76
24
65 H
11 H
20 L
20 L
4
10
82 H
18 L
73 H
9H
17 L
17 L
1L
11
72
28
66 H
6
26
26
2L
100
96
98
32
10
1000
800
460
12.2
40
8
1100
860
440
12.3
41
12
1200
840
500
12.3
%
%
%
%
%
%
%
mg/mL
umol/mL
ng/dL
ug/dL
mm3
mm3
mm3
sec
Case Study: Congestive Heart Failure
Due: December 3, 2012
Case Study Questions – Intern: Whitney Houser
I. PATHOPHYSIOLOGY
1. What are specific signs and symptoms in the patient’s physical examination that are consistent with a
diagnosis of heart failure?
Irregular heart sounds (consistent with diminished ejection fraction), jugular venous
distension in sitting position, positive hepatojugular reflux (both consistent with fluid
overload), rales in lung sounds, 4+ pedal edema, ascites (all consistent with fluid build up.
2. Outline the physiology of heart failure. Connect it to at least 3 of the signs and symptoms identified in
question 1.
The effects of coronary artery disease and hypertension, like Mr. Livermore suffered from,
put extensive pressure on the arterial walls of the heart, overtime weakening them, causing
them to work less efficently. When the left ventricle is weakened, it is unable to perform
systolic contraction efficently and blood remains in the heart which decreases the amount of
blood that reached other body tissues including the kidneys. When the kidneys do not
receive an adequate blood supply, the renin-angiotensis and aldosterone secretion systems
are activated which causes vasoconstriction and fluid/solute retention. This response is
intended to force the body to increase the cardiac output. Blood backs up in the pulmonary
veins when it cannot leave the heart. The increased pressure on the small vessels leads to
congestion which may lead to edema if fluid in blood leaks from weakened vessels into the
interstitial spaces. This back up leads to lack of oxygen rich blood being delivered to the
heart which leads to congestive heart failure.
In the case of Mr. Livermore's ascites, pedal edema and positive hepatojugular reflux: CHF
(congestive heart failure) means symptomatic heart failure with fluid build up in peripheral
tissues. It can happen on either the right or left side. In the case of common left side CHF,
the left ventricle weakens which causes inadequate blood emptying. This decreases the
stroke volume and the starves the body's tissues of oxygen and nutrients. The decreased
output sends a signal to the kidneys to stimulate renin-angiotensin and aldosterone secretion
causing water and sodium retention and vasodialation in efforts to increase the blood volume
and stimulate flow. The increased blood volume creates a backup of blood within the
peripheral veins and increased blood pressure. Fluid from blood leaks into the surrounding
tissue (i.e: legs, abdomen, liver) and pools excessively.
3. Explain the clinical manifestations and differences between Right-sided and Left-sided heart failure.
Right-sided failure (diastolic) and left-sided failure (systolic) differ in that Right-sided
failure is occurs when the heart becomes weak and is unable to pump blood effectively while
left-sided failure occurs when cardiac tissue hardens and when it contracts it is unable to
relax, blood is unable to fill the heart with as much ease as it should. The clinical
Case Study: Congestive Heart Failure
Due: December 3, 2012
manifestations of diastolic failure include an ejection fraction of less than 40-45%. Edema is
common in right side failure, the left ventricle can't bring blood in which increases pressure
and blood flows back into the lungs, starving the right side and damaging it. The right side
becomes weak and cannot pump, blood then backs up in veins causing pressure, fluid leaks
out and fills the interstitial space around the lungs and commonly in their legs and ankles as
well.
Where as a heart in systolic failure will have an ejection fraction above 45% because
pushing blood out is not a problem, its relaxing so blood can fill it again that is complicated
by the stiff tissue. The heart cannot pump properly and it skips beats. Their ejection fraction
will likely be normal although symptoms of CHF still exist.
http://wichita.kumc.edu/hastings/pedaledema.pdf
http://www.ehow.com/facts_6019506_difference-left-sided-heart-failure_.html
Concord Hospital CHF handouts from RD
4. What is cardiac cachexia? What is the role of heart disease in the development of cardiac cachexia? Explain.
Cardiac cachexia is defined as a sort-of hypermetabolism in HF patients, where they are unable
to eat enough to maintain lean tissue. It is defined clinically as HF patients with a 7.5% loss of
previous dry weight over 6 months or longer. Heart disease is thought to play a role in the
development of cardiac cachexia because when the heart is unable to pump blood efficiently the
following is likely to increase, all contributing to extreme wasting: early satiation, dyspepsia,
protein enteropathy, portal hypertension (malabsorption of lipids/protein), increased metabolic
rate because of how much harder the heart has to work to pump blood out and relax to allow it
to fill again, liver congestion. Anorexia is secondary to a lack of nutrient rich blood being
delivered to and from the heart.
Nutrition and Diagnostic-Related Care Manual, Escott-Stump, p. 352, 353
5. Explain the relationship of sodium restriction in the treatment of heart failure. What is the
recommendation for outpatient heart failure patients?
In heart failure, the decreased blood output sends a signal to the kidneys to stimulate reninangiotensin and aldosterone secretion causing water and sodium retention and vasodialation
in efforts to increase the blood volume and stimulate flow. The increased blood volume
creates a backup of blood within the peripheral veins and increased blood pressure. Fluid
from blood leaks into the surrounding tissue (i.e: legs, abdomen, liver) and pools excessively.
The body is already retaining sodium and fluid, increasing pressure on vessel walls and
causing fluid to leak out into interstitial spaces including the space around the heart and
lungs. Sodium intake will effect whether more fluid is retained, increasing this pressure and
allowing even more fluid to seep into the space around the heart, making it harder for it to
pump and weakening it even further. Recommendation: MNT: 2000mg/day, tailor to
patient; limit fluid intake to 1500ml/day.
Case Study: Congestive Heart Failure
Due: December 3, 2012
Nutrition Therapy and Pathophysiology, Nelms et. al, p 324-327.
6. Explain rationale for fluid restriction in heart failure patients.
Similarly, the decreased blood output sends a signal to the kidneys to stimulate reninangiotensin and aldosterone secretion causing water and sodium retention and vasodialation
in efforts to increase the blood volume and stimulate flow. The increased blood volume
creates a backup of blood within the peripheral veins and increased blood pressure. Fluid
from blood leaks into the surrounding tissue (i.e: legs, abdomen, liver) and pools excessively.
The body is already retaining sodium and fluid, increasing pressure on vessel walls and
causing fluid to leak out into interstitial spaces including the space around the heart and
lungs. Too much fluid intake will increase this pressure and allowing even more fluid to seep
into the space around the heart, making it harder for it to pump and weakening it even
further. The fluid has no where to go if the kidneys begin to not do their job as well.
Recommendation: limit fluid intake to 1500ml/day.
7. What foods are counted as fluid?
Any food that is liquid at room temp or can be liquified: jello, watermelon, all obvious fluids like
water, juice, coffee, tea, broth.
II. NUTRITION ASSESSMENT
8. What factors affect the assessment and interpretation of Dr. Livermore’s weight and body composition? Dr.
Livermore’s weight was 165 lbs on admission; his weight three days later was 145 lbs. How does his weight
change during the first week of hospitalization?
Fluid retention will greatly effect how you must interpret his weight and body composition.
Accounting for fluid is essential to get an accurate assessment. He was put on Lasiks which is a
diuretic to help him lose some of the fluid retention, the weight change is likely because of that
loss.
9. Calculate Dr. Livermore’s energy and protein needs. Explain your rationale for the weight you choose to
use in your calculation.
(10 x 66kg) + (6.25 x 178cm) - (5 x 85yo) + 5=1,352 REE for a 145lb man with AF. I used his
weight 3 days after admission with the understanding that althugh it may not be 100%
accurate, it is likely more accurate than the pre-diuresed weight of 165.
1,352 x AF (1.3) x stress factor (1.2) = ~2100kCal
Protein needs: 1.3-1.5g/kg: 86-99g
http://www.slideshare.net/azamjafri/importance-of-nutrition-in-hospitalizedpatients#btnNext
Case Study: Congestive Heart Failure
10. Calculate Dr. Livermore’s fluid requirements.
Due: December 3, 2012
1,400-1900ml/day (48-64oz/day, 30ml/oz)
Nutrition and Diagnosis-Related Care, Escott-Stump, p. 358.
11. Ultimately Dr. Livermore received nutrition support via enteral feeds. Select an appropriate enteral formula
and calculate his total volume and goal rate to meet his needs.
Jevity 1.5, energy dense formula to ensure he meets his needs while avoiding fluid overload.
2100/1.5=1400kCal (total kCals needed/kcal per ml in selected formula=kcal needs from
formula)
1400/24=58.3ml/hr goal rate (kcal needs from formula/24 hours=goal rate)
12. Identify Dr. Livermore’s abnormal laboratory values. For each value include the normal value, patient’s value,
Reason for abnormality and the nutritional implication.
BUN, Creatinine, CPK, Ammonia, Alk Phos: Indicative of impaired kidney function.
ALT, AST: An indication of hepatic disease, could be the result of hepatic hypertension from
CHF.
LDH: A sign that tissue is being broken down, potentially a sign of anorexia.
LDL, HDL-C, VLDL, LDL/HDL, Apo A, Apo B: All indicate hyperlipidemia and are correlated
with cardiovascular disease.
T3: Elevated thyroid hormones could indicate a hypermetabolic state, likely in CFH patients
who are burning through lean tissue and burning hundreds of calories straining to function.
13. Below are some of Dr. Livermore’s medications, for each explain their use and the nutritional implications of
use.
a. Lanoxin
Rationale for Use – Helps correct arterial fibbrilation, keep his heart rate steady and
even.
Nutritional Implications – Lanoxin users are at risk for magnesium loss. Lanoxin reduces
the amount of intracellular mg which can also result in refractory hypokalemia and
hypocalcemia.
Toffaletti J. Analyt Chem 1991 63(12):192R-194R; al-Ghamdi SM, et al. Am J
Kidney Dis 1994 Nov;24(5):737-752.
b. Lasix
Rationale for Use – Diuretic to rid him of excess fluid build up.
Nutritional Implications – Lasix use can result in potassium, magnesium and thiamin
loss.
c. Dopamine
Rationale for Use – Used as a vasodialator and blood pressure medicine, works to
Case Study: Congestive Heart Failure
Due: December 3, 2012
inhibit renal sodium reabsorption.
http://www.ncbi.nlm.nih.gov/pubmed/12189316
Nutritional Implications – Similar to Lasix, excessive loss through urine can effect
electrolyte balances including potassium, calcium and magnesium levels.
d. Thiamin
Rationale for Use – Supplemented to replace the thiamin lost in diuresing the patient
with Lasix. Diuretics can interfer with the metabolism of Thiamin and a deficiency
can result in serious neurological and nervous system consequences.
Nutritional Implications – N/A
III. NUTRITION DIAGNOSIS
14. List possible nutrition problems from both the Clinical and the Intake domain.
Elevated BUN lab value, Inadequate intake
15. Select two of the high-priority nutrition problems from question 14 and complete PES statements for them.
Impaired renal funtion r/t congestive heart failure aeb elevated renal output lab values
including BUN 34, NH3 120, Phos 190.
Inadequate energy intake r/t increased needs associated with disease state aeb unintentional
weight loss
16. Due to diarrhea Dr. Livermore was unable to tolerate his tube feed. What recommendations could be made to
increase the tolerance of his tube feed?
Slow the rate of feeding, if a gtube, check gastric residuals more often to insure tolerance.
17. Dr. Livermore’s tube feeding was discontinued. Alongside the contraindication for parenteral nutrition due to
fluid restriction, Dr. Livermore had expressed verbally that he wanted oral feedings only. What would you
recommend to maximize Dr. Livermore’s oral intake?
I would start him on an anti-emetic to control his nausea and begin him on a full liquid diet
including Ensure Plus and guage his tolerance from there. I would attempt to increase his
calories slowly.
18. Dr. Livermore’s living will expressed the desire for oral feeding and palliative care. What is the dietitian’s role
in palliative care?
Palliative care or comfort measures includes continuing to eat. RDs play a role in working with
the patient and their families to determine the best course of action to decide what foods they
will tolerate and enjoy and cause them to remain comfortable in their disease state and not
suffer any hunger pangs or have their condition decline.