Heart failure in primary care: a practical case study for clinicians

Nur509 Assignment

Heart failure in primary care: a practical case study for clinicians

This paper presents a realistic primary care case study of a 70-year-old male with chronic ischaemic heart disease and heart failure. You will find practical steps for assessment, diagnostic priorities, treatment planning, and follow-up, arranged for a 10 to 15 slide presentation with a five minute voice-over. Older adults carry a disproportionate burden from heart failure and hospital readmissions, so primary care choices influence outcomes. Clinical guidelines emphasize early diagnosis, focused use of natriuretic peptides, and guideline-directed medical therapy for heart failure with reduced ejection fraction. I use contemporary guideline recommendations and recent primary care research to justify clinical choices. The writing targets clinicians who need clear, actionable material for a short teaching presentation. References follow Harvard style and include peer-reviewed sources published between 2019 and 2023. (Heidenreich et al., 2022) PubMed

Subjective data: case presentation
Patient is a 70-year-old retired teacher who lives with a spouse and manages activities of daily living independently. Chief complaint is progressive exertional breathlessness over three weeks with ankle swelling by evening. Onset was gradual after a self-limited upper respiratory infection, with orthopnea requiring two pillows and one episode of paroxysmal nocturnal dyspnea this month. The patient reports intermittent central chest discomfort with exertion, relieved by rest, no syncope, no palpitations at rest. Past medical history includes myocardial infarction five years earlier, hypertension, and type 2 diabetes managed with metformin. Current medications list shows lisinopril 10 mg daily, metoprolol succinate 50 mg daily, furosemide 40 mg daily, atorvastatin 40 mg nightly, aspirin 81 mg daily, and metformin 1 g twice daily. No known drug allergies. Social history notes a 30 pack-year prior smoking history, quit ten years ago, and minimal alcohol intake.

Objective data: examination and tests
Vital signs on arrival show blood pressure 150 over 88 mmHg, heart rate 92 beats per minute and regular, respiratory rate 18 breaths per minute, oxygen saturation 95 percent on room air, temperature 36.8 degrees Celsius. Cardiac exam reveals elevated jugular venous pressure, a displaced apical impulse, and an S3 gallop. Lung auscultation finds bibasal crackles to one third of the fields with no focal consolidation. Peripheral exam shows bilateral pitting ankle edema to the mid tibia. Electrocardiogram demonstrates inferior Q waves consistent with prior infarction and no acute ischemic changes. Chest radiograph shows mild cardiomegaly with pulmonary venous congestion. Transthoracic echocardiogram reports left ventricular ejection fraction 35 percent with regional wall motion abnormality. Use of natriuretic peptide testing and echocardiography for diagnostic confirmation aligns with guideline recommendations for primary care assessment of suspected heart failure (NICE, 2018; Heidenreich et al., 2022). NICE+1

Assessment: differential and primary diagnosis
Differential diagnosis includes decompensated ischemic cardiomyopathy, acute coronary syndrome presenting without troponin rise, and volume overload due to renal dysfunction or medication nonadherence. Presence of prior myocardial infarction, reduced ejection fraction, elevated BNP, and signs of congestion supports a primary diagnosis of heart failure with reduced ejection fraction secondary to ischaemic cardiomyopathy. Regular pulse and normal high-sensitivity troponin reduce the probability of ongoing large myocardial injury. Risk stratification should address hemodynamics, renal function, electrolytes, and arrhythmia risk, alongside frailty and cognitive status in this older adult. Discussing goals of care with the patient and spouse helps align therapy intensity with patient preferences. Referral to cardiology for ischemia evaluation fits the picture when anginal symptoms persist or arrhythmia emerges. Document baseline functional status and medication history before major medication changes. (Heidenreich et al., 2022) PubMed

Plan: laboratory, diagnostic and pharmacologic strategy
Order urgent repeat serum chemistry with electrolytes and creatinine, liver function tests, thyroid function tests, fasting lipids, and repeat BNP to track response. Repeat ECG and consider ambulatory rhythm monitoring if new palpitations occur. If ongoing angina symptoms or objective ischemia appears, arrange coronary angiography after shared decision making with cardiology. Start guideline-directed medical therapy for HFrEF in a stepwise fashion with close monitoring for renal dysfunction and hyperkalaemia. Initiate or optimise renin angiotensin system blockade, titrate a beta blocker to tolerated target, add a mineralocorticoid receptor antagonist for persistent symptoms or low ejection fraction, and introduce a sodium glucose co-transporter 2 inhibitor as part of baseline therapy. Use loop diuretics for symptom control with a plan for dose adjustment guided by daily weights. Coordinate pharmacist-supported medication reconciliation and schedule early clinical review within seven days after major medication changes. (Heidenreich et al., 2022) PubMed

Non-pharmacologic measures and medication review
Counsel the patient on daily weight monitoring, fluid awareness, and dietary sodium reduction to a personalised target set with the patient. Arrange referral to outpatient cardiac rehabilitation for supervised exercise and functional recovery, adapted to comorbidities and mobility. Update immunisations with influenza and pneumococcal vaccines as part of prevention. Conduct a structured medication review with a pharmacist and primary care team to identify potentially inappropriate medications and opportunities for deprescribing. Recent trials of electronic decision support for medication review in primary care produced mixed results for improving appropriateness, but such interventions proved safe and feasible in older adults with polypharmacy (Jungo et al., 2023). A realist synthesis of multidisciplinary deprescribing identifies pharmacist integration, shared decision making, and tailored follow-up as implementation essentials in primary care (Radcliffe et al., 2023). Use these principles to prioritise high-yield deprescribing targets and to protect renal and hemodynamic stability during GDMT titration. PubMed+1

Role of the nurse practitioner and multidisciplinary care
Nurse practitioners serve as care coordinators, titration leaders, and patient educators in heart failure management. Nurse-led clinics and NP involvement reduce readmissions, improve access, and support timely therapy adjustments in heart failure cohorts (King-Dailey et al., 2022). Use nurse-led follow-up to monitor weights, renal function, blood pressure, and adherence after medication changes. Integrate remote monitoring when available to flag early decompensation and to prioritise clinic visits for high-risk patients. Involve a clinical pharmacist for reconciliation and a physiotherapist for rehabilitation planning. Ensure clear communication lines with cardiology for device therapy or revascularisation decisions. Document roles and handover steps in the care plan so the team operates with shared responsibility and predictable follow-up. PMC

Presentation structure and practical tips for Canvas Studio
Design ten concise slides that cover objectives, the case narrative, focused exam findings, essential investigations, the differential, the primary diagnosis, the management plan, guideline alignment, the nurse practitioner role, and references. Use one slide per major heading so you keep the narrative tight for a five minute voice-over. On the management slide highlight the immediate actions, short term monitoring, and the follow-up schedule in bullet form. On the guideline slide cite specific recommendations for diagnosis and for guideline-directed medical therapy to justify your choices to a clinical audience. Use the nurse practitioner slide to show how roles split across the team and to present a clear follow-up algorithm for seven day review, two week titration checks, and routine three month assessment. Keep each slide visually spare, use large fonts, and place key data points in the speaker notes for narration. Prepare a short script that states the clinical question, offers the working diagnosis, and closes with the single action you want the audience to remember.

References
Heidenreich, P.A., Bozkurt, B., Aguilar, D., Allen, L.A., Byun, J.J., Colvin, M.M., Deswal, A., Drazner, M.H., Dunlay, S.M., Evers, L.R., Fang, J.C., Fonarow, G.C., Hayek, S.S., Hernandez, A.F., Khazanie, P., Kittleson, M.M., Lee, C.S., Link, M.S., Milano, C.A., Nnacheta, L.C., Sandhu, A.T., Stevenson, L.W., Vardeny, O., Vest, A.R., Yancy, C.W., 2022. 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure. Circulation, 145(18), e876–e894. PubMed

Knuuti, J., Wijns, W., Saraste, A., Capodanno, D., Barbato, E., Funck-Brentano, C., Prescott, E., Storey, R.F., Deaton, C., Cuisset, T., et al., 2020. 2019 ESC Guidelines for the diagnosis and management of chronic coronary syndromes. European Heart Journal, 41(3), 407–477. PubMed

Jungo, K.T., Ansorg, A.-K., Floriani, C., Rozsnyai, Z., Schwab, N., Meier, R., Valeri, F., Stalder, O., Limacher, A., Schneider, C., Bagattini, M., Trelle, S., Spruit, M., Schwenkglenks, M., Rodondi, N., Streit, S., 2023. Optimising prescribing in older adults with multimorbidity and polypharmacy in primary care (OPTICA): cluster randomised clinical trial. BMJ, 381, e074054. PubMed

Radcliffe, E., Servin, R., Cox, N., Lim, S., Tan, Q.Y., Howard, C., Sheikh, C., Rutter, P., Latter, S., Lown, M., Fraser, S.D.S., Bradbury, K., Roberts, H.C., 2023. What makes a multidisciplinary medication review and deprescribing intervention for older people work well in primary care? A realist review and synthesis. BMC Geriatrics, 23, 591. BioMed Central

King-Dailey, K., Frazier, S., Bressler, S., King-Wilson, J., 2022. The role of nurse practitioners in the management of heart failure patients and programs. Current Cardiology Reports, 24, 1945–1956. PMC

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Nur509 Assignment 7.

Do the presentation based on a 70-year-old male with a history of cardiac disease. This will be a case study in primary care setting.

Presentation: Realistic Clinical Case Study
For this assignment, you will develop a presentation on a realistic clinical case on a topic that is of interest to you. And then, use Canvas Studio’s Screen Capture feature to record (voice-over) your presentation. Develop your presentation based on a clinical case that was seen during your experience or a topic that is of interest to you. How do I record a Canvas Studio video with a webcam in a course?
Content Requirements You will create a PowerPoint presentation with a realistic case study and include appropriate and pertinent clinical information that will be covering the following:
1. Subjective data: Demographics; Chief Complaint; History of the Present Illness (HP1) that includes the presenting problem and the 8 dimensions of the problem; Medications; Allergies; Past medical history; Family history; Past surgical history; Social history; Review of Systems (ROS) 2. Objective data: Vital signs; Physical exam, Labs (reviewed from the patient’s medical records, if no lab/diagnostic tests were done recently to review, you must indicate that to receive credit). 3. Assessment: Differential diagnosis; Primary Diagnosis 4. Plan: Laboratory and diagnostic tests; Pharmacologic treatment plan; Non-pharmacologic treatment plan; Anticipatory guidance (primary prevention strategies); Follow up plan. 5. Other: Incorporation of current clinical guidelines; Integration of research articles; Role of the Nurse practitioner
Submission Instructions:
• The presentation is original work and logically organized, formatted, and cited in the current APA style, including citation of references. • The presentation should consist of 10-15 slides and less than 5 minutes in length. • Incorporate a minimum of 4 current (published within the last five years) scholarly journal articles or primary legal sources (statutes, court opinions) within your work. Journal articles and books should be referenced according to APA style (the library has a copy of the APA Manual).