Question

Ed is a 65-year-old Caucasian man with a significant cardiovascular history. He is being treated with amlodipine 10 mg by mouth daily for his stage 1 hypertension and atorvastatin 80 mg by mouth daily for his dyslipidemia. He has reported to his primary care provider with complaints of shortness of breath (SOB) x 1 month. His last medical appointment was a year ago.

Review of Systems Subjective Data General: Easily fatigued with normal, everyday activity Skin: Denies rashes, lesions or itching 2 HEENT: Denies visual or hearing changes, allergies, dizziness, rhinorrhea, colds or respiratory changes Cardiac: Denies chest pain, tightness or palpitations; blood pressure readings at home 140-150s/80-90s Respiratory: SOB with normal activities such as sweeping the floor; sleeps in a recliner at night due to difficulty breathing when lying flat; denies asthma or other respiratory disorders GI: Denies N/V, GERD, gallbladder problems, or PUD; last fecal occult blood test negative GU: Denies pain, burning, hesitancy, blood or urgency with urination MS: Feels stiff in the mornings but good overall Neuro: Denies weakness, paresthesias or changes in speech or memory Psych: Denies feeling depressed or down Physical Examination Ht. 70 inches, Wt. 185 pounds, BP 156/92 mmHg, T 97.8F, P 80, R 20; SpO2 94% General: Appears healthy, well-groomed; shortness of breath noted after walking from the waiting room to the exam room Eyes: PERRLA; EOM intact Neck: Positive JVD; negative thyromegaly; trachea midline; absent lymphadenopathy Heart: RRR; no murmur, rubs, gallops, lifts or heaves; no tenderness to palpation Lungs: CTA bilaterally; symmetrical chest expansion Abdomen: (+) BS x 4, soft, non-tender, no masses, no organomegaly or bruits Extremities: 1+ pitting edema to lower extremities bilaterally Laboratory Tests: N-terminal (NT)-pro hormone BNP (NT-proBNP) 1202 pg/mL with an unremarkable basic metabolic panel (BMP); other labs not available at this time Diagnostic Tests: Electrocardiogram demonstrates left ventricular hypertrophy (LVH); Echocardiogram reveals an ejection fraction of 30% Diagnoses After This Visit: Stage 2 hypertension, heart failure with reduced ejection fraction, dyslipidemia, atherosclerosis Currently Prescribed Medications:  Discontinue amlodipine  Continue atorvastatin 80 mg by mouth daily  Begin lisinopril 5 mg by mouth daily  Begin furosemide 20 mg by mouth daily 3  Begin metoprolol succinate 25 mg by mouth daily  Return to the clinic in 1 week Module 2 Case Analysis Discussion Points 1. Relate the pathophysiology (what is happening within the body) of heart failure (HF) to specific assessment findings in the data provided. Discuss only the abnormal signs and symptoms that could be a direct result of HF including abnormal lab values and other diagnostic findings. When discussing these findings, relate Ed’s findings to normal, expected findings and discuss why the abnormality occurs secondary to HF (the pathophysiology should explain what is happening within the body as a result of the disease process.) Support your discussion with references. 2. There are two major schemes for classifying HF severity – the New York Heart Association (NYHA) classification and the American College of Cardiology/American Heart Association (ACC/AHA) scheme. What stage of HF would Ed be classified as having based upon these classification schemes? Discuss both schemes and support your analysis with assessment data. Provide references. 3. Discuss Ed’s newly prescribed drug therapy for his HF (lisinopril, furosemide, metoprolol succinate). For each of the three medications, address the purpose, mechanism of action, metabolism and excretion, dosing and adverse effects. Address each topic for each of the three medications to receive full credit. Support your discussion with references. 4. How does Ed’s pharmacological treatment plan for his HF align with recommendations provided by the American College of Cardiology/American Heart Association/Task Force on Clinical Practice Guidelines and the Heart Failure Society of America? Are his prescribed medications appropriate based upon these recommendations? A link to the guidelines can be found in your learning module. Provide rationale and references to support your response. 5. Analyze ALL of Ed’s prescribed medications for the potential of drug-drug interactions. Discuss any potential drug-drug interactions and precautions that should occur because of those risks (i.e., should a medication be discontinued or should there be close monitoring of certain things, etc...).

Answer 1

Q. No. 1. Answer :

Pathophysiology of heart failure :

* Due to dislipidemia, Reduced ejection fraction, and Atherosclerosis, there is an decreased blood circulation.

* there is an decreased left ventricular function.

* there is a stimulation of renin angiotensin system leads to vasoconstriction.

* Aldosteron stimulation leads to sodium water retention and decreases excretion of fluids.

* And increased fluids over load leads to Heart failure.

Signs and symptoms :

* here in the patients Electrocardiogram Ejection fraction is

30 %.

* The normal is 65%.

* so if the ejection fraction is below 40% indicates the body does not getting sufficient blood flow according to needed.

* Due to Left ventricular hypertrophy here the ejection fraction is below the normal range.

* Here the patient is having N terminal pro BNP ( Brain nitro uretic peptide) value is 1202 pg per ml.

* it is high, the normal values are 125 pg per ml.

* If the increasing of BNP values indicates more chance to heart failure, and also kidney problems.

* here the patient is having high values.

* Chest pain and palpations due to decreased oxygen supply.

* parasthesia and changes in speech due to lack of blood circulation to brain.

* distended jugular veins.

Q. No. 2. Answer :

Mr. Ed's having class ll heart failure, because here the client is having

* Short ness of breath with normal activities.

* Chest pain and

* palpitations ect.

This is according to NYHA classification.

But in class l heart failure no symptoms can see like short ness of breath while walking and climbing the stairs.

Q. No. 3. Answer :

lisinopril :

Purpose :

it is used to treat the congestive heart failure and hypertension.

Mechanism of action :

It inhibits the angiotensin converting enzyme. So that angiotensin l does not converts into angiotensin ll. So that decreases the retention of sodium and water.

Side effects :

* dizziness,

* cough,

* hyper kalemia,

* head ache,

* low blood pressure,

* chest pain,

* fatigue.

Metabolism and excretion :

It dose not metabolizes, excretion through urine.

Furosimide :

Purpose :

It's a loop diuretic, it prevents the absorption of sodium in the body.

It is used in congestive heart failure patients and kidney patients.

Mechanism of action :

It blocks the absorption of sodium, water and chloride from filtered fluid from kidneys. It may increases the urine out put so those electrolytes may looses through urine.

Dose : 40 mg.

Side effects :

* increased urination,

* thirsty,

* muscle cramps,

* itching,

* rashes,

* weakness,

* diarrhea,

* dizziness. Ect.

Metabolisms and excretions :

Metabolise in liver and excretion through bile.