Congestive Heart Failure

General Information
Case no.	6.A Congestive Heart Failure
Authors	Kelly M. Lindenberg, PT, MSPT, PhD, CSCS Melissa L. Bednarek, PT, DPT, PhD, Board Certified Clinical Specialist in Cardiovascular & Pulmonary Physical Therapy Kala M. Markel, PT, DPT
Diagnosis	Heart failure with atrial fibrillation
Setting	Emergency Department with transfer to Telemetry Unit
Learner expectations	☑ Initial evaluation ☐ Re-evaluation ☐ Treatment session
Learner objectives	Explain the pathophysiology of the patient’s diagnosis. Relate the pathophysiology of cardiovascular disorders to the clinical manifestations and activity/participation limitations seen in physical therapy practice. Select, implement, and interpret physical therapy interventions based on the medical examination findings. Develop an understanding of medical management and how it influences physical therapy plan of care.

Medical
Chief complaint	Shortness of breath, fatigue
History of present illness	Patient is a 73-year-old male who presents to the emergency department with increasing severity of shortness of breath over the past 2 days. He reports a decreased tolerance for activity, requiring frequent rest breaks. Patient denies chest pain, nausea, or vomiting. He reports currently having an upper respiratory infection, self-treating with Sudafed. Patient is to be admitted for medical workup and management.
Past medical history	Remote history of ST elevation myocardial infarction (STEMI) with stent placement 5 years ago, atrial fibrillation, hypertension, hyperlipidemia, osteoarthritis, cholecystectomy, anxiety/depression.
Past surgical history	Right total knee arthroplasty
Allergies	Penicillin
Medications	Coumadin, Prinivil, Lopressor, Lipitor, Tylenol
Precautions/Orders	Bed rest

Social history
Home setup	Lives in a two-story home with wife. Flight of steps with unilateral rail to enter home. Flight of steps with bilateral rails to the second floor. Has two adult children, one lives nearby; has two grandchildren.
Occupation	Retired computer analyst.
Prior level of function	Independent with functional mobility and activities of daily living. Independent for stairs; however, required increased time. Spouse manages cooking/cleaning. Poor tolerance for yard maintenance, hired help. (+) Driver
Recreational activities	Vacation planned over summer to celebrate 50th wedding anniversary. Enjoys reading, watching travel television shows, and fishing.

Vital signs	Hospital day 0: emergency department	Hospital day 1: telemetry unit
Blood pressure (mmHg)	108/58, MAP = 75	134/78, MAP = 97
Heart rate (beat/min)	153, irregular rhythm	102, irregular rhythm
Respiratory rate (breath/min)	26	18
Pulse oximetry (SpO₂)	91% on room air	96% on 2 L O₂ via nasal cannula
Temperature (°F)	99.1	99.2
Body mass index	31.5	—————————————

Imaging/Diagnostic test	Hospital day 0: emergency department	Hospital day 1: telemetry unit
EKG	1. Atrial fibrillation with rapid ventricular rate	1. Atrial fibrillation with rapid ventricular rate
Chest X-ray	1. Cardiomegaly, bilateral interstitial and alveolar infiltrates involving predominantly the mid- and lower lung fields Fig. 6.1	—————————————
Transesophageal echocardiogram (TEE)	1. Ejection fraction, 40%; no signs of thrombus	1. Ejection fraction, 45%; no signs of thrombus

Fig. 6.1 Cardiogenic pulmonary edema. Cardiomegaly, bilateral interstitial, and alveolar infiltrates involving predominantly the mid- and lower lung fields. (Source: Burgener F. Disease. In: Burgener F, Kormano M, Pudas T, ed. Differential Diagnosis in Conventional Radiology. 3rd ed. Stuttgart: Thieme; 2007.)

Medical management	Hospital day 0: emergency department	Hospital day 1: telemetry unit
Medications	1. IV Cardizem 2. Coumadin 3. Prinivil 4. Lopressor 5. Lipitor	1. PO Cardizem 2. Coumadin 3. Prinivil 4. Lopressor 5. Lipitor 6. Lasix
Respiratory	1. Supplemental oxygen: 2 L via nasal cannula	1. Supplemental oxygen: 2 L via nasal cannula 2. Incentive spirometer, 10 times/hour
Consults	1. Cardiology	1. Physical therapy 2. Occupational therapy
Precautions	1. Telemetry 2. Fall risk 3. Bed rest	1. Telemetry 2. Fall risk 3. Activity as tolerated

Lab		Reference range	Hospital day 0: emergency department	Hospital day 1: telemetry unit
Complete blood count	WBC	5.0–10.0 × 10⁹/L	11.5	11.7
	RBC	4.5–5.5	4.5	4.3
	Hemoglobin	14.0–17.4 d/dL	17	15
	Hematocrit	42–52%	40	39
	Platelet	150–400 k/μL	240	230
Electrolyte panel	Na	134–142 mEq/L	133	130
	K	3.7–5.1 mEq/L	3.7	3.8
	Ca	8.6–10.3 mg/dL	9.0	8.6
	Cl	98–108 mEq/L	107	108
	PO₄	2.3–4.1 mg/dL	2.9	3.2
	Mg	1.2–1.9 mEq/L	1.3	1.5
Lipid panel	HDL	> 40 mg/dL	38	——————
	LDL	< 100 mg/dL	110	——————
	Triglyceride	< 150 mg/dL	155	——————
	Cholesterol	< 200 mg/dL	180	——————
Bleeding ratio/viscosity	INR	0.8–1.2	2.5	2.3
Bleeding ratio/viscosity	Physical therapy	11–13 seconds	11	12
Cardiovascular-specific labs	Troponin—1	< 0.03 ng/mL	0.02	——————
	BNP	< 100 pg/mL	280	650
	CK	30–170 U/L	80	——————
Other	Glucose	70–100 mg/dL	120	118
	BUN	6–25 mg/dL	22	26
	Creatinine	0.7–1.3 mg/dL	1.6	1.9

Pause points
Based on the above information, what are the priority Examination tests and measures? Outcome measures? Treatment interventions?

Pause points

Based on the above information, what are the priority

Examination tests and measures?
Outcome measures?
Treatment interventions?

Hospital Day 2, Telemetry Unit: Physical Therapy Examination
Subjective
“I am just so tired and have no energy to get up.”
Objective
Vital signs	Pre-treatment			Post-treatment
Vital signs	Supine	Sitting	Standing	Sitting
Blood pressure (BP; mmHg)	124/78	118/74	128/76	See post-mobility vital signs below
Heart rate (HR; beat/min)	88	96	104
Respiratory rate (RR; breath/min)	18	22	24
Pulse oximetry on 2 L/O₂ via nasal cannula (SpO₂)	96%	94%	93%
Modified BORG scale—dyspnea	2/10	2/10	3/10	2/10
Pain	0/10	0/10	0/10	0/10
General	Patient supine in bed, head of bed elevated at 30 degrees Lines/tubes/drains notable for telemetry, 2 L/O₂ via nasal cannula, IV access via left antecubital, urinary catheter
Head, ears, eyes, nose, and throat (HEENT)	Unremarkable
Cardiovascular and pulmonary	Normal sinus rhythm 2 L/min O₂ via nasal cannula Auscultation: mildly diminished breath sounds and fine crackles in bilateral posterior lower lobes, S3 heart sound Pulse: 1 + bilateral dorsalis pedis Edema: 2 + foot to 1 inch above lateral malleolus (+) JVD at 5 cm above sternal angle
Gastrointestinal	Reports constipation
Genitourinary	Urinary catheter in place Input and Output (I&O) incongruence per EMR (I > O), now stabilizing
Musculoskeletal	Range of motion	Bilateral upper extremity (BUE): within functional limit (WFL) Bilateral lower extremity (BLE): WFL with the exception of bilateral knees—right knee flexion at 100 degrees, left knee extension limited at 10 degrees
	Strength	B shoulder flexion: 4/5 B elbow flexion: 5/5 B elbow extension: 5/5 B wrist extension: 5/5 B wrist flexion: 5/5 B hip flexion: 4/5 B hip abduction: 4/5 B knee flexion: 4/5 B knee extension: 4/5 B ankle dorsiflexion: 5/5 B ankle plantarflexion: 5/5
	Aerobic	Not formally assessed Reported 3/10 on RPE Scale during transfers
	Flexibility	Not formally assessed On observation, bilateral pectoralis major/minor and bilateral hamstring tightness, rounded shoulder posture.
	Posture	Sitting: forward head, rounded thoracic spine Standing: forward head, rounded thoracic spine, flattened lumbar spine
Neurological	Balance	Static sitting, unsupported: independent Dynamic sitting, unsupported: supervision Static standing, unsupported: close supervision Dynamic standing, unsupported: close supervision
	Cognition	Alert and oriented x 4
	Coordination	Finger-to-nose: intact bilaterally Heel-to-shin: intact bilaterally
	Cranial nerves	II–XII: intact
	Reflexes	Biceps: 2 + bilaterally Patellar: 2 + bilaterally
	Sensation	BLE dermatomes: intact to light touch
	Tone	BUE and BLE: normal throughout
Functional status
Bed mobility	Supine to left side lying: supervision with head of bed elevated 30 degrees and use of bedrails Left side lying to sitting: supervision with head of bed elevated 30 degrees and use of bedrails
Transfers	Sit to/from stand: supervision
Ambulation	Ambulated 75 feet with close supervision and no assistive device Gait deviations notable for decreased cadence, decreased heel strike at initial contact bilaterally, and flexed posture Gait speed: 0.6 m/s Vital signs post ambulation: BP: 140/78, HR: 116, RR: 28, SpO₂: 91% on 2 L NC 1-minute recovery: BP: 142/76, HR: 103, RR: 22, SpO₂: 94% on 2 L NC 3-minute recovery: BP: 132/74, HR: 98, RR: 18, SpO₂: 95% on 2 L NC
Stairs	Ascend/descend four 6-inch steps with bilateral handrails with contact guard assistance Vital signs post–stair negotiation: BP: 144/76, HR: 124, RR: 30, SpO₂: 90% on 2 L NC 1-minute recovery: BP = 130/76, HR: 112, RR: 25, SpO₂: 92% on 2 L NC Worsening crackles with lung auscultation, (+) mild accessory muscle breathing

Assessment
☑ Physical therapist’s	Assessment left blank for learner to develop.
Goals
Patient’s	“I just want to get out of this hospital.”
Short term	1. Goals left blank for learner to develop. 2.
Long term	1. Goals left blank for learner to develop. 2.

Plan
☑ Physical therapist’s	Will treat patient once daily, five days per week at bedside for functional mobility and endurance building activities. Treatment may include lower body ergometer; diaphragmatic breathing training; functional mobility training such as transfers, ambulation, and stair training; and patient education on energy conservation and symptom awareness.

Bloom’s Taxonomy Level	Case 6.A Questions
Create	1. Synthesizing the medical data and physical examination findings, develop an appropriate physical therapy assessment of the patient. 2. Develop two short-term physical therapy goals, including an appropriate timeframe. 3. Develop two long-term physical therapy goals, including an appropriate timeframe.
Evaluate	4. Interpret the patient’s vital sign response to ambulation.
Analyze	5. What does the TEE result on hospital day 0 suggest about the patient’s cardiac function? 6. What does the presence of crackles during auscultation suggest about the patient’s condition?
Apply	7. Design two physical therapy interventions that address the patient’s goals
Understand	8. What does the jugular venous distention test assess for? What do the results indicate? 9. What is the relationship between atrial fibrillation and heart failure?
Remember	10. Why does the patient’s chest X-ray reveal cardiomegaly? 11. How is pitting edema quantified?