Question

History of Present Illness

H.J. presented to the emergency department (ED) late one evening complaining of a “racing

heartbeat”. She is an overweight, 69-year-old white female, who has been experiencing

increasing shortness of breath for the past two months and marked swelling of the ankles

and feet for the past three weeks. She feels very weak and tired most of the time and has

recently been waking up in the middle of the night with severe breathing problems. She has

been sleeping with several pillows to keep herself propped up. Five years ago, she suffered

an anterior wall (left ventricle) myocardial infarction (MI). She received coronary artery

bypass surgery 4 ½ years ago for obstructions in the left anterior descending and left

circumflex coronary arteries. The patient is admitted to the hospital for a thorough

examination.

Family History

Atherosclerosis – Father died of a heart attack (MI)

Cerebral vascular accident (CVA) – Mother had several CVAs

Medical History

MI in 2014

Hypercholesterolemia x 9 years

Osteoarthritis

Gout

Obesity

Three-pack per day cigarette smoker x 30 years but quit smoking after her heart attack

Uses alcohol infrequently

Surgical History

Coronary artery bypass surgery (CABG) after MI in 2014

Medication

Allopurinol 200mg daily

Atorvastatin 20mg daily

Aspirin 81mg daily

Metoprolol succinate ER 50 mg daily

Ramipril 5mg daily

Allergies

Nuts, shellfish, strawberries – rashes and hives

Hydralazine – itchiness and hives

Physical Examination and Laboratory Tests

Vital signs

BP= 125/80 (left arm, sitting)

HR = 125 bpm and regular

RR = 28 breaths per minute and labored

BT = 98.5 °F (oral)

SpO2 = 92% on room air

Weight = 215 lbs, Height = 5’8’’

Skin

Pale and cool extremities, slightly diaphoretic

Neck

Neck supple with no bruits over carotid arteries

Positive JVD

Lungs

Bibasilar rales with auscultation

Heart

PMI displaced laterally

Normal S1 and S2 with distinct S3 at apex

No murmurs

Abdomen

Soft to palpation with no masses

Significant hepatomegaly and tenderness on deep palpation

Extremities

2+ pitting edema in feet and ankles extending bilaterally to mid-calf region

Cool and sweaty skin

Radial, dorsalis pedis, and posterior tibial pulses present

Neurological

Alert and oriented to place, person, time, and situation

Cranial and sensory nerves intact

Chest X-ray

Prominent cardiomegaly and consistent with pulmonary edema

Echocardiogram

Ejection fraction (EF) = 36%

Laboratory Blood Test

Result

Na+

153 mEq/L

K+

3.2 mEq/L

BUN

45 mg/dL

Creatinine

2.3 mg/dL

Question 1

. Based on the information given above, do you suspect that this patient has

developed left-sided HF, right-sided HF, or total (both left and right HF)?

Question 2

. Based on the information given above, this patient likely has systolic or

diastolic HF? Explain the rationale.

Question 3

. How did you arrive at your answer to question 1?

Question 4

. What is the likely cause for H.J.’s heart failure?

Question 5.

Identify

three

risk factors that likely contributed to the patient’s heart attack

(MI) in 2014.

Question 6.

Why is the patient taking aspirin?

Question 7.

Why is this patient tachycardic?

Question 8.

Why is this patient tachypneic?

Question 9.

Explain the pathophysiology of the abnormal skin manifestations in this

patient’s compensated HF.

Question 10.

Are jugular vein distension (JVD) and hepatomegaly signs of left-sided HF or

right-sided HF? Explain the rationale.

Question 11.

Explain the pathophysiology of the abnormal serum Na+ and K+ levels in this

patient’s compensated HF.

Question 12.

Explain the pathophysiology of the abnormal serum BUN and creatinine

levels.

References (please list all references below

Answer 1

is based on the information given above, do you sauspect that this patient has left sided if right sided HE or both & en A According to the information the patient is having left ventrice obstruction which is coronary blockade that is major risk for left sider heart failure. Usually a deft sided heart failure increases burden on right sided heart later which may leads to right sided failure. Here the pt had symptoms of right sided failure like positive JVD, bibasilar males in lings due to fluid back up in lungs slight hepatomegaly chest xray shows out Cardiomegaly with pulmonary oedoma, swelling of legs, ankles due to fluid, shortners of breath CrOB) fatigue. So here the patient is currently having right sided heart failure due to left sided failure due to blockade earlier. 2) Based on information given above this pt likely has yetoke I diartolic heart fafture A) Syatokee heart failure means heart is not contracting will to supply oxygenated blood to body usually soon in left sided heart failure. Diastolic heart failure it means heart is unable to relax properly and blood

having diastolic patient is The sided heart failure. . It is also called as a is not pumping in properly. I right sided heart failure corrently with previous lot sided failure. 3. It arrived to answer to question I bared on that urually left sided heart failure Mesults in Maht sided heart failure and the patient is showing sigue of right sida failure with positive lungs, Jvd, pulmonary oedema, erales in slight hepatomegaly, sob. swelling of ankles due to fluid accumulation 4A) What are causes for H. Is heart failure & > Pact history of Coronary artery disease Ceto) Here, the pt had past history of coronary black in left ventricle and also undergone coronary artery bypass graft CCA BG) which is major rist. Snooking (Three pack per day & 30 gr) > Family history (Father died of heart attack (MI) mother had several cras

Hypercholestremia. 54) Three alex factors those are likely contributed to patients mi z Hypercholestromia lobe city - Smoking (three packs a day x 3692) > Family Wictory father died of heart attack, mother had several CIA's). GAY why is patient having aspiring Aspirin is antiplate let agent. It prevents the formation of blockade in coronary artery. That means it prenents atherosclerosis. 7A) why is the patient tachycardie & As a compensatory mechanism heart tries to compon- - sate to fulfill body needs for Oxygenated blood by increasing heart beats per minute. So patient is tachycardic.

e) why palitent is tochupuolet Since the patient le having sexeve severe shortnout of breath. Due to respiratory gates in the body. pulmonary badema the imbalance of 94 Falling hart vol 1 HR retrength of contraction Dolated heart strength of decompensation contraction 1 End diastolle volume an End o Bp systolic volunga neontract like syurgathats aching preloader & nye nour 1 HR voor Wonal blood lavoronto flow 1 afterload Hard A renin Dulmonary tovatov Angiotensin-I a sodium rotention 1 blood Volume Major manifestation

THE 104) Jugular nenove distension and hepatomegaly are of alght cided failure. Due to fluid back up en right sided heart. Due to the right rided failure. blood from jugular neine cruable to pump into right rum due to which fluid backup occur in Jugut veins, abdomen due to which Ivo hepatomegaly ocena se tension. Des to øde sodiuw AY IN CHE due to decreated Cardiac output it leadt deere are in stenal brood hoo flow which leads to increated Veuin recretion from kidney that activated "Remin angiotensin aldosterone system CRAAS) mesult in more conversion of angiotowsing - rends that leads to more sodium retensions which hyper natremia / Na level are seen tupo kam is seen due to more délution (fruid acumulation 124) In this pt Bun is 45 maldl, sr. cx-2-8 mg/dl. In CHF Pts due to arterial under fitting leads to t SNS esympathe bie nervous system), RAAS athvike that from Portat increases the absorption of coclivan water ↑ Urea concentrations, collecting flow. n. duct urine night artrial pressure, & glomerular filtration to A BUN, Jr. co are seen a