Reference no: EM133468574

An 84-year-old woman with known heart failure presented with dyspnea for 4 weeks during which time she developed dyspnea and fatigue on minimal exertion and even at rest. She also complained of orthopnea and reported that most of the past week she slept sitting in a recliner. Prior to sleeping on a recliner, she had had one episode of paroxysmal nocturnal dyspnea. Her past medical history was remarkable for hypertension. She denied chest pain, palpitation or dizziness. She also reported right upper quadrant pain associated with nausea and loss of appetite but no vomiting. She had chronic leg swelling which has gotten so severe over the past several weeks that she could not wear her shoes. She responded to her worsening symptoms by restricting her activities and did not see her physician. At the emergency department, her jugular venous pressure was elevated at 15 cm of water. She had positive hepatojugular reflux, a right-sided third heart sound and an enlarged soft tender liver. She had no pulmonary râles or wheezing. She had severe bilateral pitting edema in both of her legs up to mid-thigh areas with multiple blisters over lower legs. She also had evidence of venous insufficiency with brown pigmentation and induration of skin. A loud second heart sound at left fourth intercostal space suggested that her estimated pulmonary artery systolic pressure was elevated at 40-45 mm Hg. She had normal sinus rhythm by an electrocardiogram. Her chest radiograph was remarkable for marked cardiomegaly and pulmonary venous congestion. Her prior left ventricular ejection fraction was unknown and a subsequent echocardiogram revealed a left ventricular ejection fraction of >55%.

Outline a treatment plan which is detailed and focused based upon your diagnoses for this patient. Explain your clinical decision making and why each treatment would be essential to the treatment of this patient.