CASE #1: Mrs. Emilia Garcia History of

CASE #1: Mrs. Emilia Garcia History of Present Illness Mrs. Garcia, a 74-year-old female, presents to the Emergency Department with increasing shortness of breath, especially with exertion, and swelling in her feet and ankles. She feels very tired. Mrs. Garcia states she noticed a couple weeks ago that she was getting short of breath and more tired when taking her daily walk around the block. It has been getting worse the past few days and she has had to shorten her walks. She noticed her feet and ankles started swelling a few days ago, and it is worse today. She was dizzy this morning when she stood up. She has gained about 5 pounds since she last weighed herself a week ago. Past Medical History Hypertension Dyslipidemia Class II Congestive Heart Failure (CHF) – diagnosed 2 years ago, EF 40% at time of diagnosis Peptic ulcer with H. pylori infection – diagnosed last year, treated, and confirmed resolution Cesarean section at age 26, gravida 1, para 1 Current Medications Hydrochlorothiazide 25 mg daily Lisinopril 10 mg daily Propranolol 100 mg daily Omeprazole 20mg daily Acetaminophen 650 mg q 8 hrs prn TUMs OTC prn Physical Examination VITAL SIGNS: Temperature = 97.6, Pulse (P) = 108, Respiratory rate (RR) = 26, Blood pressure (BP) = 92/50, Oxygen saturation (O2 sat) = 88% on room air (RA), pain 1/10, Weight (Wt) = 70 kg., Height (Ht) = 167.6 cm GENERAL: Alert and oriented to person, place, and time. She is tachypneic, fatigued, and appears to be in mild respiratory distress. HENT: PERRLA, moist mucous membranes, dentition intact NECK: Jugular vein distention (JVD) up to ears when sitting at 90 degrees, no bruits, large, distended neck veins CARDIAC: Tachycardia regular, S3 present, without noticeable murmur, or rub LUNGS: Bilateral crackles in bases. No use of accessory muscles, no retractions. ABDOMEN: Soft, non-tender, bowel sounds present NEURO: Slight tremors noted in both arms/hands at rest. EXTREMITIES: 2+ palpable pulses, 3+ edema in bilateral lower extremities Labs: CBC: WBC, 7.1, Hgb 12.1, Hct 37.3, Plts 172 CMP: Na+ 138, K+ 3.9, Cl- 106, CO2 28, Creatinine 1.8, BUN 27, Ca 9.0 BNP: 1734 pg/mL Troponin: 0.0 ECG: Sinus tachycardia Imaging: Chest x-ray shows bilateral pleural effusions, moderate cardiomegaly Echocardiogram: EF = 35% QUESTIONS Based on her medical history, what was/were the likely cause(s) of her heart failure? Briefly describe the link between the potential cause(s) and the development of left ventricular failure. 2. What do her elevated BNP levels indicate? A) The patient’s renal function is insufficient the clear the BNP waste product from the blood. B)The patient has third-degree heart block. C) The patient’s blood pressure is insufficient to perfuse the myocardium. D)The patient is in heart failure. 3. What is/are the physiological cause(s) of her ‘jugular vein distension,’ peripheral edema, and recent rapid weight gain? Group of answer choices A) Right sided heart failure, leading to elevated systemic vein pressure, and systemic edema.. B) Left sided heart failure, leading to elevated systemic vein pressure, and systemic edema. C)End stage renal failure, leading to fluid overload and hypertension. D)Left sided heart failure, leading to pulmonary hypertension and pulmonary edema. 4. What is the likely explanation for the patient’s bilateral crackles and bilateral pleural effusions? Group of answer choices A)End stage renal failure, leading to fluid overload and hypertension. B)Right sided heart failure, leading to increased pulmonary blood pressure and pulmonary edema. C)Left sided heart failure, leading to increased pulmonary blood pressure and pulmonary edema. D)Left sided heart failure, leading to elevated systemic vein pressure, and systemic edema. 5. Why are ACE inhibitor medications such as lisinopril effective at improving cardiac function in patients with heart failure? In other words, what effects do ACE inhibitors have that allow the heart to function more effectively? 6. Mrs. Garcia takes hydrochlorothiazide (HCTZ) daily. What is the specific target of HCTZ and how is that different from the target of loop diuretics, like furosemide? 7. How does the use of diuretics help a patient with heart failure? In other words, what effect do diuretics have and how is that effect related to heart function? 8. Mrs. Garcia’s creatinine and BUN levels are elevated. What does this indicate about her renal function? Group of answer choices A) Mrs. Garcia’s renal function can only be determined using an exogenous marker and a 24 hour urine collection to measure actual glomerular filtration rate. B) Mrs. Garcia’s renal function is no longer keeping up with her body’s production of waste products. C) Mrs. Garcia’s renal function has returned to normal due to the significant decrease in her blood pressure. D) Creatinine and BUN levels are independent of renal function. 9. This patient’s history of peptic ulcers is a contraindication for the use of NSAIDs. What impact do NSAIDs have that increases the risk of developing peptic ulcers? Group of answer choices A) NSAIDs inhibit histamine production. In the stomach histamine promotes HCl acid formation, which protects the stomach from H. pylori infection. In the absence of histamine the stomach’s pH increases, allowing infiltration of H. pylori and the production of peptic ulcers. B) NSAIDs inhibit prostaglandin production. In the stomach, prostaglandins promote mucus production, which is protective of the gastric cells. A decrease in prostaglandins and mucus production leaves the stomach cells more exposed to the effects of the stomach’s low pH. C) NSAIDS inhibit stomach motility, which allows food to remain in the stomach for extended periods. The pressure from the food resting on the gastric mucosa produces a kind of “pressure ulcer” that can develop into a peptic ulcer. D) NSAIDs are used to manage pain and have no impact on stomach physiology. 10. This patient takes omeprazole daily. What is the target of omeprazole and how does the effect of omeprazole on that target decrease the risk of peptic ulcers? Group of answer choices A) CFTR channels are blocked, leading to a decrease in Cl- transport and a subsequent decrease in HCl acid production, thereby decreasing the risk of peptic ulcers from excess acid in the stomach. B) Histamine H2 receptors are blocked, leading to a decrease in acid production and a decrease in the risk of peptic ulcers from excess acid in the stomach. C)Hydrogen/Potassium ATPase pumps are inhibited, leading to a decrease in acid production and a decrease in the risk of peptic ulcers from excess acid in the stomach. D) Mucous cells are stimulated to increase production of protons.

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