What is the best course of action for a 58-year-old patient with a past medical history (PMH) of anxiety and insomnia, presenting with occasional edema in her feet and hands, who has been unable to follow up with cardiology due to difficulties in obtaining laboratory results, particularly kidney function tests, and is now seeking to re-establish care and refill medications?

From the Guidelines

This 58-year-old patient with anxiety, insomnia, and peripheral edema needs prompt follow-up with cardiology and completion of previously ordered tests to ensure optimal management of her symptoms and prevention of potential complications. I recommend immediately scheduling a cardiology appointment to review the results of her previous Doppler and echocardiogram from 9/24, as these may provide crucial information about her reported swelling 1. Given her difficulty with blood draws, alternative methods for assessing kidney function should be explored, such as non-contrast imaging or modified testing protocols. Her medication regimen should be continued as previously prescribed until she can be evaluated by cardiology.

The patient's symptoms of anxiety and insomnia should be addressed, and cognitive behavioral therapy for insomnia is recommended as first-line treatment before the initiation of sedating antidepressants or melatonin receptor agonists 1. The patient should also reschedule the sleep study that was ordered six months ago, as sleep disorders may be contributing to her cardiovascular symptoms. For her peripheral edema, elevating her legs when sitting, limiting salt intake, and wearing compression stockings may provide symptomatic relief.

Her application for disability would benefit from complete medical documentation, so ensuring follow-up with all specialists is essential. The combination of cardiac concerns, pulmonary issues, and mental health conditions suggests a complex clinical picture that requires coordinated care between her specialists to properly manage her symptoms and provide appropriate documentation for her disability application. Regular follow-up with cardiology, pulmonology, and counseling for PTSD is crucial to ensure that her symptoms are well-managed and that she receives the necessary support for her disability application 1.

From the FDA Drug Label

DOSAGE AND ADMINISTRATION Edema Therapy should be individualized according to patient response to gain maximal therapeutic response and to determine the minimal dose needed to maintain that response. The dose of Furosemide tablets may be carefully titrated up to 600 mg/day in patients with clinically severe edematous states.

The patient's symptoms of occasional swelling in feet and hands suggest edema, and furosemide may be considered for treatment. The initial dose for edema is 20 to 80 mg, and the dose may be titrated up to 600 mg/day for severe edematous states.

• The patient's difficulty in obtaining labs and cardiology testing due to kidney function issues should be considered when initiating furosemide therapy.
• Close monitoring of the patient's response to furosemide and adjustment of the dose as needed is recommended 2.

From the Research

Patient's Medical History and Current Condition

• The patient is a 58-year-old with a past medical history (PMH) of anxiety and insomnia, and reports occasional swelling in her feet when standing for too long.
• She has cardiology on her case and has undergone a doppler and echo on 9/24, but was unable to follow up with the cardiologist.
• The patient also reports occasional swelling in her hands and has seen a lung doctor for a lung study.
• She is currently seeing a counselor for PTSD and is applying for disability.

Specialist Care and Treatment

• The patient has cardiology and pulmonology specialists on her case.
• She has been referred for a sleep study, but was unable to complete it 6 months ago.
• Today, the patient is in the clinic to get re-established with cardiology and to refill her medications.
• According to 3, early recognition of advanced heart failure is crucial to optimize care, and delayed referral or lack of referral can have adverse consequences.
• The use of diuretics, such as furosemide, is a common treatment for heart failure, and subcutaneous administration may be a viable option for some patients, as seen in 4.

Diagnostic Testing and Assessment

• The patient has undergone a doppler and echo, but was unable to follow up with the cardiologist.
• She has been referred for a sleep study, but was unable to complete it 6 months ago.
• According to 5, a thorough cardiac assessment is essential to identify cardiac dysfunction, and investigations such as echocardiography and blood tests can aid in differential diagnosis.
• The patient's inability to obtain labs due to past drug use may make it challenging to assess her kidney function, which is essential for cardiology testing, as noted in 6.

Treatment Options and Management

• The patient may benefit from advanced heart failure therapies, such as those discussed in 3.
• The use of diuretics, such as furosemide, may be effective in managing the patient's congestion, as seen in 4 and 7.
• According to 6, a continuous intravenous furosemide infusion may be a viable option for managing persistent congestion in advanced heart failure patients.
• The patient's treatment plan should be tailored to her individual needs and clinical situation, taking into account her PMH, current condition, and any co-morbidities, as discussed in 7.