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Report generated on 12/3/2023, 7:45:14 AM America/Denver Performance Overview fo The following table summarizes your performance on each section of the case, whether you completed that section or not. Time spent: 7hr 3min 17sec Status: Submitted Case Section Status Your Score Time spent Performance Details History Done 66% 1hr 25min 54sec 100 questions asked, 31 correct, 16 missed relative to the case's list Physical exams Done 100% 23min 35sec 82 exams performed, 16 correct, 0 partially correct, 0 missed relative to the case's list Key findings organization Done 1min 7sec 13 findings listed; 9 listed by the case Problem statement Done 2min 31sec 125 words long; the case's was 67 words Differentials Done 38% 15min 24sec 9 items in the DDx, 3 correct, 5 missed relative to the case's list Differentials ranking Done 38% (lead/alt score) 25% (must not miss score) 0sec Tests Done 75% 1hr 50min 46sec 6 correct tests ordered, 6 extraneous, 2 missed relative to the case's list Diagnosis Done 100% 8sec Management plan Done 2hr 28min 4sec 778 words long; the case's was 111 words Exercises Done 42% (of scored items only) 6min 33sec 3 of 8 correct (of scored items only) 1 partially correct Attempt: 2957890

Report generated on 12/3/2023, 7:45:14 AM America/Denver History Notecard by on case Susi Green Use this worksheet to organize your thoughts before developing a differential diagnosis list. 1. Indicate key symptoms ( Sx ) you have identified from the history. Start with the patient's reason(s) for the encounter and add additional symptoms obtained from further questioning. 2. Characterize the attributes of each symptom using "OLDCARTS" . Capture the details in the appropriate column and row. 3. Review your findings and consider possible diagnoses that may correlate with these symptoms. (Remember to consider the patient's age and risk factors.) Use your ideas to help guide your physical examination in the next section of the case. HPI Sx = Sx = Sx = Sx = Sx = Sx = Onset Location Duration Characteristics Aggravating Relieving Timing / Treatments Severity Attempt: 2957890

Diagnosis: CHF/Heart Failure with preserved ejection fraction (HFpEF) DIAGNOSTIC TESTS >12 Lead ECG: Normal sinus rhythm with left ventricular hypertrophy and with left atrial enlargement Serial echocardiograms can find changes in ejection fraction (EF), structural remodeling, and valvular function. ECG provides crucial information including worsening ventricular or valvular function. This can also be used as a follow- up assessment of LVEF and remodeling after a patient receive treatments (American College of Cardiology, 2022). >BNP: high 10 Measurement of BNP and NT-proBNP levels in a suspected cardiac cause of patient with dyspnea symptoms provides an additional diagnostic value to clinical judgment when the cause of dyspnea is vague and the physical examination is ambiguous. In the emergency setting, they are more useful for ruling out HF. The higher levels have high positive predictive value to diagnose heart failure (American College of Cardiology, 2022). >CXR Pulmonary edema, cardiomegaly In patients with suspected heart failure, a chest x-ray is ordered to assess the size of the heart and congestion in the lung. This also detect other cardiac and pulmonary diseases such as pneumonia, that may have caused the symptoms of the patient (American College of Cardiology, 2022). >Troponin I <0.03 Cardiac enzymes such as Troponin confirms if a heart attack has occurred and the extent of the damage (American Heart Association, 2023). >ABG: PaO2 36, SaO2 71% Low oxygen levels is a sign that the heart is not pumping enough oxygen-rich blood to the body, as one of the symptoms of CHF (American Heart Association, 2023). >CBC: WBC 11,100- Mild leukocytosis and Hemoglobin 13.2- mild anemia Abnormal results may indicate a strain on the heart or on other organs, which often results from heart failure. When there is not enough oxygen carried by red blood cells, the heart moves at a faster heart rate to move the small number of cells and becomes overtaxed from the effort (American Heart Association, 2023). MEDICATIONS >Increase frequency of patient's Hydrochlorotiazide to 25 mg 1 tab PO 2x daily To prevent morbidity, patients with HFpEF and hypertension needs to have medication titrated to reach a blood pressure targets in line with the published clinical practice guidelines. Thiazide diuretics such hydrochlorothiazide are considered in patients with hypertension and HF with mild fluid retention. In patients with evidence of congestion or fluid retention, diuretics should be prescribed. This also helps avoid recurrent symptoms (American College of Cardiology, 2022). >Start Jardiance (empagliflozin) 10 mg 1 tab PO daily SGLT2i empagliflozin showed a significant benefit in symptomatic patients with HF with LVEF >40% and elevated natriuretic peptides, according to the study of Empagliflozin Outcome Trial in Patients with Chronic Heart Failure with Preserved Ejection Fraction. The study also found that it showed a significant reduction in total HF hospitalizations, a decrease in eGFR decline, and a fair improvement in quality of life in patients at 52 weeks (American College of Cardiology, 2022).

Report generated on 12/3/2023, 7:45:14 AM America/Denver CONSULTS/REFERRALS >Refer patient to cardiac rehab An exercise rehabilitation program is appropriate for patients with HF who are in stable medical condition and are capable in participating in an exercise program. This program includes a medical evaluation, to educate patients on the importance of medical adherence, dietary recommendations, psychosocial support, and an exercise training and physical activity counseling program. This results in an improvement in functional capacity, exercise tolerance, reduce overall and HF-specific hospitalization rates, and improve quality of life (American College of Cardiology, 2022). CLIENT EDUCATION >Instruct patient on heart healthy/low sodium diet (hand-out provided) A common nonpharmacologic treatment for patients with HF symptomatic with congestion is restricting dietary sodium. The American Heart Association (AHA) currently recommends a sodium intake of <2300 mg/d for general cardiovascular health promotion. The DASH diet suggest food rich in antioxidants and potassium, which achieves sodium restriction but still provides adequate nutrition, along with dietary counseling (American College of Cardiology, 2022). >Instruct on importance of physical activity/exercise (hand-out provided) Safe exercise training in patients with HF has numerous benefits. In a major study of exercise and HF, exercise training shows a significant reduction in cardiovascular disease mortality or hospitalizations after risk factors adjustments (American College of Cardiology, 2022). FOLLOW-UP Appointment made for follow-up in a week Once HF diagnosis is made, it is urgent to start aggressive proven therapy. Initiating while optimizing doses sooner before further worsening allows better achievement of guideline-derived medical treatment and prevent clinical status deterioration. Most medications attain target dosing over a titration period of 2 to 4 months with 1- to 4- week cycles along with 1 to 3 dosing changes (American Heart Association, 2023). REFERENCES American College of Cardiology. (2022). 2022 AHA/ACC/HFSA Guideline for the management of heart failure. https://www.jacc.org/doi/pdf/10.1016/j.jacc.2021.12.012? _ga=2.144845372.960274267.1700773542-885749656.1690130099 American Heart Association. (2023). Heart failure. https://www.heart.org/en/health-topics/heart-failure Attempt: 2957890

Allergies Category Data entered by Allergies NKDA Preventive Health Category Data entered by Preventive health up to date with immunizations Last physical unknown Family History Category Data entered by Family History husband and grown children- healthy father, deceased @ 65 y/o- Parkinson disease related complications; mother, deceased - massive stroke. family history of colorectal cancer. Social History Category Data entered by Social History eats regular diet, drinks a glass of wine once or twice/wk hy of smoking @ 19 y/o x17 years- quit 26 years ago denies recreational drugs, no exercise Review of Systems

Category Data entered by General She is overall healthy with hy of HTN, COPD, anxiety, and depression. She c/o shortness of breath and severe difficulty breathing She denies fatigue denies difficulty sleeping, Integumentary / Breast denies swelling to BLE's HEENT / Neck denies headaches, blurred vision, hearing problem, ear pain, sinus problems, sore throats, nasal congestion, or difficulty swallowing Cardiovascular denies palipations or chest pain, tightness or heavy chest, denies excessive sweating denies BLE edema reports eating pizza (high sodium) in the last few days Respiratory reports severe difficulty breathing and SOB denies SOB at rest, denies cough, denies being awaken at night of SOB, sleeps with one pillow, denies wheezing, denies recent upper respiratory infection, Gastrointestinal denies weight gain or weight loss denies change in appetite Genitourinary denies incontinence or urgency Musculoskeletal denies muscle or joint pain denies swelling to BLE's Allergic / Immunologic denies fever, NKDA Endocrine denies excessive sweating or change in appetite Hematologic / Lymphatic denies chronic blood loss Neurologic denies headaches, episodes of fainting or lightheadedness Psychiatric reports depression symptoms sometimes and some anxiety issues Physical Exams Category Data entered by General Patient is A&Ox4, appears to be stressed/anxious, sitting upright in bed with marked increase in respiratory

Cardiovascular elevated BP 155/90 S4 gallop at auscultation Dynamic auscultation has no significant change while standing, squatting, during Valsalva maneuver or with sustained handgrip No jugular venous distention (JVD) asystole observed to be less than 3 seconds and/or fall in systolic observed to be less than 50 mmHg PMI quarter-sized, brisk, and tapping in the 5th intercostal space (ICS) at the mid-clavicular line (MCL) 1.0 to 1.4 ratio of ankle to brachial BP- negative for PVD Chest / Respiratory Lung sounds clear all lung fields, no wheezing, bronchi, or rale sitting upright in bed with marked increase in respiratory effort, catches breath mid sentence, marked use of accessory muscles, RR at 26- labored breathing, O2 sat- 70%, negative finding from chest palpation SpCO 3% eTCO2 33 mmHg Abdomen Abdomen is flat and symmetric with no scars, deformities, striae or lesions Normoactive bowel sounds Negative findings from abdominal/femoral arteries auscultation No mass or tenderness No hepatosplenomegaly Genitourinary / Rectal deferred Musculoskeletal / Osteopathic Structural Examination No swelling or deformity. No cyanosis, clubbing or extremity edema. range of motion equal bilaterally Strength is 5/5 bilaterally Normal bulk and tone No rigidity Neurologic balance tests found negative finding 3/3 registration and recall. Attention intact. Names 2/2 objects accurately. Able to follow multi-step commands. Spatial and executive function intact on drawing task. Score: 30/30 No involuntary movements

Psychiatric Patient is A&Ox4, appears to be stressed/anxious Lymphatic No pathologically enlarged lymph nodes in the cervical, supraclavicular, axillary or inguinal chains Attempt: 2957890