Clay is an 8-year-old boy diagnosed with heart failure. Which of the following shows that he is strictly following the directed therapeutic regimen?
A. Daily use of an antibiotic
B. Pulse rate less than 50 beats/minute
C. Normal weight for age
D. Elevation in red blood cell (RBC) count
Correct Answer: C. Normal weight for age
Adequate weight for height demonstrates adequate nutritional intake and lack of edema. Symptoms of heart failure include those due to excess fluid accumulation (dyspnea, orthopnea, edema, pain from hepatic congestion, and abdominal distention from ascites) and those due to a reduction in cardiac output (fatigue, weakness) that is most pronounced with physical exertion.
Option A: Daily use of antibiotics is not indicated in heart failure. Diuretics, beta-blockers, angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, angiotensin receptor neprilysin inhibitor, hydralazine plus nitrate, digoxin, and aldosterone antagonists can produce an improvement in symptoms.
Option B: A pulse rate less than 50 beats/minute, bradycardia, probably indicates digoxin toxicity. Chronic presentations (months) differ in that fatigue, anorexia, abdominal distension, and peripheral edema may be more pronounced than dyspnea. The anorexia is secondary to several factors including poor perfusion of the splanchnic circulation, bowel edema, and nausea induced by hepatic congestion.
Option D: An elevated RBC count demonstrates polycythemia. Cardiac troponin (T or I), complete blood count, serum electrolytes, blood urea nitrogen, creatinine, liver function test, and brain natriuretic peptide (BNP). BNP (or NT-proBNP) level adds greater diagnostic value to the history and physical examination than other initial tests mentioned above.