Question

History of Present Ilness HJ. 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 / 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

Answer 1

9.

Due to inadequate cardiac output, due to the hearts inefficiency to pump effectively, triggers the sympathetic nervous system and the neurohormonal responses, which in turn causes diaphoresis. Cool and clammy extremities are a result of low cardiac output, which indicates low perfusion.

10. Jugular venous distention and hepatomegaly are signs of right sided heart failure.

• The inability to pump blood by the right ventricle causes back up of blood in the right atrium which in turn causes increased pressure in the superior vena cava and the inferior vena cava.
• Increased pressure and congestion in the superior vena cava causes congestion of veins draining from the upper part of the body, which results in jugular venous distention.
• Increased pressure in the inferior vena cava in turn causes increased pressure and congestion in the other veins that drain into it including the hepatic veins, hence hepatomegaly.

11.

Reduced renal blood flow and glomerular filtration rate causes activation of renin- angiotensin - aldosterone mechanism, enhanced sympathetic nervous system activity and vasopressin release. These factors evoke potent vasoconstriction, retain sodium and water and cause hypokalemia and hypomagnesemia.

Hence, the patient has hypernatremia and hypokalemia.

12.

Due to less renal blood flow and glomerular filtration rate the kidneys are unable to excrete the waste products like urea and creatinine, this results in the increased BUN and creatinine values in heart failure.

References:

• www.mayoclinic.org
• http://en.m. Wikipedia. org. wiki