Differential Diagnosis
The patient's presentation suggests a complex clinical picture with multiple potential diagnoses. Here's a categorized differential diagnosis:
Single most likely diagnosis
- Acute Decompensated Heart Failure (ADHF): The patient's symptoms of orthopnea (improvement in dyspnea when standing by the window for fresh air), paroxysmal nocturnal dyspnea, bilateral pitting edema, third heart sound, and bilateral basal coarse crepitations are classic for heart failure. The patient's history of hypertension, which has been poorly controlled (defaulted follow-up for over 6 months), further supports this diagnosis as uncontrolled hypertension is a major risk factor for the development of heart failure.
Other Likely diagnoses
- Hypertensive Emergency: Given the patient's high blood pressure (170/110 mmHg) and symptoms of end-organ damage (e.g., heart failure), this is a likely consideration. The presence of a third heart sound and bilateral edema suggests that the high blood pressure is having a significant impact on cardiac function.
- Pulmonary Edema: This could be a component of the patient's presentation, given the bilateral basal coarse crepitations and symptoms of dyspnea. However, it is likely secondary to the heart failure rather than a primary pulmonary issue.
- Chronic Kidney Disease (CKD): Although not directly diagnosed, the patient's long-standing hypertension could have led to CKD, contributing to fluid overload and edema.
Do Not Miss (ddxs that may not be likely, but would be deadly if missed.)
- Pulmonary Embolism (PE): While the patient's presentation is more suggestive of heart failure, PE could cause sudden onset dyspnea and tachycardia. It's crucial to consider PE, especially if there are any risk factors (e.g., recent immobilization, cancer), as it requires immediate anticoagulation.
- Cardiac Tamponade: Although less likely given the absence of specific signs like pulsus paradoxus, it's a condition that could lead to cardiac collapse and must be considered in the differential, especially if there's a suspicion of myocardial infarction or other conditions leading to tamponade.
- Aortic Dissection: This is a hypertensive emergency that could present with sudden onset of severe pain and potentially signs of heart failure if the dissection involves the aortic root. It's a diagnosis that cannot be missed due to its high mortality rate.
Rare diagnoses
- Constrictive Pericarditis: This could present with signs of heart failure, but it's less likely given the patient's history and the absence of a pericardial knock on examination.
- Restrictive Cardiomyopathy: Similar to constrictive pericarditis, this is a rare condition that could mimic heart failure but would typically have different echocardiographic findings.
Immediate Intervention
Given the most likely diagnosis of Acute Decompensated Heart Failure (ADHF), immediate interventions should focus on:
- Oxygen Therapy: To improve oxygen saturation and reduce dyspnea.
- Nitrates: Such as nitroglycerin to reduce preload and afterload, thus decreasing the workload on the heart and improving symptoms of heart failure.
- Diuretics: Loop diuretics like furosemide to reduce fluid overload and edema.
- Beta-blockers and ACE inhibitors: If not already on these, they should be considered for long-term management of heart failure and hypertension, but their initiation may need to be cautious in the acute setting depending on the patient's blood pressure and clinical status.
- Monitoring: Close monitoring of the patient's vital signs, oxygen saturation, and clinical status for any signs of deterioration.
- Echocardiogram: To assess left ventricular function and rule out other cardiac causes of the patient's symptoms.
- Laboratory Tests: Including complete blood count, electrolytes, renal function tests, and troponins to evaluate for any underlying causes or complications.