Chief Complaint (CC) \"I\'ve been feeling really lousy lately. I have no energy

Question

Chief Complaint (CC) "I've been feeling really lousy lately. I have no energy whatsoever and I'm always cranky. HPI (history of present illness) TJ. is an 80 year old man who presents to the VA Hospital for a routine checkup. Upon questioning, he states he "has been feeling weak and terrible" for nearly 6 months now but has not experienced any loss in weight. PMH (past medical history) Multiple DVT (deep venous thrombosis) with chronic venous insufficiency Type 2 DM (diabetes mellitus) HTN (hypertension) Hyperlipidemia

Explanation / Answer

Risk factors that have placed this patient at folate deficiency are,

Vital signs show increase in pulse rate and decreased oxygen saturation which are features of impending heart failure.

Absence of shortness of breath indicates that it is not left sided heart failure. Jugular genius distension, ankle swelling, enlarged liver and spleen in this patient points to the presence of right heart failure.

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