Chief Complaint“I can no longer lie down flat because I can’t breathe and I’vegained 3 pounds in 3 days.”HPIBizzy Fuller is a 64-year-old female with a history of ischemiccardiomyopathy with last known EF 25% (ECHO 1.5 years ago). Shepresents to the emergency department with approximately 2–3 days ofincreasing shortness of breath, and she reports having gainedapproximately 3 lb over the past 3 days. She also notes that shehas had increasing leg swelling over the same time period. Over thepast week, the patient has noted increasing bloating in her abdomenand has felt slightly nauseated. She has had problems with diarrheaand constipation since her cholecystectomy several months ago. Shehas been on a fiber supplement, from which she has derived somebenefit. She states that she had been on torsemide many years agobut for an unknown reason was switched to furosemide.PMHCAD (status postmyocardial infarction × 2 in early 2000s; CABGin 2000, PCI in May 2002)Paroxysmal ventricular tachycardia (status post-ICD placementin 2011)Obstructive sleep apneaDiabetes mellitus type 2DepressionDyslipidemiaMild osteoarthritisGERDSeasonal allergiesFHBoth her mother and father died of MI in their 60sSHPatient is a happily married, retired school teacher and isfully functional with ADLs. She is an occasional alcohol drinker(two to three drinks per week) and has a 30 pack-year history, butquit smoking approximately 12 years ago.MedsFexofenadine 60 mg orally BIDInsulin detemir 40 units SC at bedtimeInsulin aspart 7 units SC before each mealAspirin 81 mg orally once dailyCarvedilol 12.5 mg orally BIDDuloxetine 30 mg orally once dailyFluticasone nasal spray 50 mcg/inh one spray BIDLasix 80 mg orally BIDLisinopril 20 mg orally once dailyMeloxicam 15 mg orally daily PRN joint painNitroglycerin 0.4 mg sublingually PRN chest painSimvastatin 20 mg orally QHSRanitidine 150 mg orally BIDAllNKDAROSShe denies any fevers, chills, sweats, or coughs. She statesthat her diet has not changed recently, and she tries to watch hersalt intake, but she states that she has been nonadherent to hermedication regimen for the last 2 days, stating, “I have been toobusy to take my medicine.” She denies any significant chest painand also denies any history of additional coronary interventionprocedures since 2002. All others negative.Physical ExaminationGenA 64-year-old obese, Caucasian female in mild respiratorydistressVSBP 186/92 mm Hg, P 71 bpm, RR 32 on admission (16 currently),oxygen saturation 86–92%; T 97.5°F; Ht 5′3″; Wt 87.4 kgSkinWarm and diaphoreticHEENTNC/AT with trachea midlineNeck/Lymph NodesNeck supple, (+) JVD, no bruits, no thyromegalyLungs/ThoraxCrackles in the bases bilaterallyBreastsNormalCVRegular rate and rhythm without any murmurs, gallops, orrubsAbdSoft, nondistended, nontenderGenit/RectDeferredMS/ExtExtremities reveal 2+ pitting edema; all pulses palpableNeuroA & O × 3, CNs intact, history of depression but no apparentsymptoms at presentLabs| Download (.pdf) | PrintNa 131 mEq/LBNP 2867 pg/mLK 3.7 mEq/LTroponin 0.03 ng/mLCl 101 mEq/LWBC 8.7 × 103/mm3CO2 20 mEq/LHgb 14.1 g/dLBUN 24 mg/dLHct 42.3%SCr 1.7 mg/dLPlt 226 × 103/mm3Glu 96 mg/dLA1C 6.5%Ca 9.6 mg/dL Chest X-RayInterstitial infiltrates throughout, tiny pleural effusionsbilaterally; mild cardiomegaly; implanted defibrillator leads areat the right atrial appendage and right ventricular apex. No focalpneumonia, pneumothorax, or evidence of frank pulmonary edema.ECGSinus rhythm with occasional premature ventricular complexes; noacute ischemia indicatedAssessmentCongestive heart failure exacerbation due to medicationnonadherence; poorly controlled hypertension. Admit for medicalmanagement.2. What are the short-term goals ofpharmacotherapy regarding treatment of ADHF?3.a. What nondrug therapies might beuseful for alleviating this patient’s symptoms and preventing arecurrence of ADHF?3.b. What pharmacotherapeutic options areavailable for treatment of this patient’s ADHF?4 What drugs, doses, schedule, andduration are best for achieving the pharmacotherapeutic goals forthis patient?5. What clinical and laboratory parametersare necessary to evaluate your chosen therapy for achievement ofthe desired therapeutic outcome and to detect or prevent adverseeffects?6. What discharge education should beprovided in order to enhance adherence, ensure successful therapy,minimize adverse effects, and prevent an unplanned readmission?