68 y/o male who had an MI in April, 2015 was seen by his physician on Aug. 30, 2
ID: 3482899 • Letter: 6
Question
68 y/o male who had an MI in April, 2015 was seen by his physician on Aug. 30, 2017 presenting with shortness of breath, fatigability, and swelling of the lower extremities. Upon physical examination, the man was found to have distended jugulars and pitting edema of the ankles. His breathing was rapid (20 breaths/min) and pulmonary crackles were heard bilaterally in the lower lobes of the lungs. He had a pulse rate of 110 beats/min and a BP of 152/98. Since his MI, he was taking digoxin and hydrochlorothiazide. At the time, the Px blood and urine work showed
Blood
Values
Urine
Values
Na+ (mEq/L)
128
Na+ (mEq/L)
110
K+ (mEq/L)
3.9
K+ (mEq/L)
80
Mg2+ (mg/dL)
1.7
Mg2+ (mg/day)
19
Ca2+ (mg/dL)
8.9
Ca2+ (mg/day)
105
HCO3 (mEq/L)
30
HCO3
1.7
Creatinine (mg/dl)
1.7
Creatinine (mg/L)
2080
PAH (mg/ml)
0.013
PAH (mg/ml)
5.91
Glucose (mg/dL)
85
Glucose
0
BUN (mg/dL)
14
24hr volume (L)
1.2
pCO2 (mmHg)
45
Osmolarity (mOsm/L)
750
pH
7.31
pH
6.8
The Px was admitted at that time and was treated with 2L of 5% saline and Lasix® which removed the excess blood volume. The Px’s blood pressure, heart rate and respiratory problems were reduced. Additional lab tests indicated that the Px was experiencing left ventricular failure. Once he was stable, the Px was sent home on Sept. 2.
On Dec. 7, 2017, the Px was transported to the ER via ambulance after his daughter found him unresponsive. She told the ER physician that her father had been extremely fatigued at any level of effort, had extensive flank pain and that his mental alertness had decreased significantly over the past two weeks. Physical examination finds that the Px is doesn’t respond to questioning and appears to fall asleep during the examination. Once again, the Px exhibits excessive swelling in the lower extremities with distended jugulars. His heart rate is now 92 and irregular, his BP is 164/110. His breathing is 28 breaths/min and shallow but lung sounds are normal. His urine is dark and foamy. The ends of his fingers and toes have a bluish appearance and his abdomen is large and distended. Blood and urine values are:
Blood
Values
Urine
Values
Na+ (mEq/L)
118
Na+ (mEq/L)
310
K+ (mEq/L)
2.9
K+ (mEq/L)
108
Mg2+ (mg/dL)
0.7
Mg2+ (mg/day)
29
Ca2+ (mg/dL)
5.9
Ca2+ (mg/day)
155
HCO3 (mEq/L)
29
HCO3
13.9
Creatinine (mg/dl)
2.2
Creatinine (mg/L)
1590
PAH (mg/ml)
0.013
PAH (mg/ml)
5.91
Glucose (mg/dL)
85
Glucose
0
pCO2 (mmHg)
53
Osmolarity (mOsm/L)
400
pO2 (mmHg)
67
24hr urine volume (mL)
600
pH
7.28
pH
6.8
RBC count / µL
3.8 x 106
Hemoglobin gm/dl
9.5
An ECG was run on the Px and is shown below:
The attending physician immediately gave the Px 30 mg of propranolol and admitted the Px. An echocardiogram was conducted and showed right and left ventricular cardiomegaly.
The echocardiogram show both left and right cardiomegaly. Why is the right ventricle affected? What would you expect the pulmonary systolic pressure to be and what is the consequence of this pressure on gas diffusion? What is regulating the increased respiratory rate??
Blood
Values
Urine
Values
Na+ (mEq/L)
128
Na+ (mEq/L)
110
K+ (mEq/L)
3.9
K+ (mEq/L)
80
Mg2+ (mg/dL)
1.7
Mg2+ (mg/day)
19
Ca2+ (mg/dL)
8.9
Ca2+ (mg/day)
105
HCO3 (mEq/L)
30
HCO3
1.7
Creatinine (mg/dl)
1.7
Creatinine (mg/L)
2080
PAH (mg/ml)
0.013
PAH (mg/ml)
5.91
Glucose (mg/dL)
85
Glucose
0
BUN (mg/dL)
14
24hr volume (L)
1.2
pCO2 (mmHg)
45
Osmolarity (mOsm/L)
750
pH
7.31
pH
6.8
S+Explanation / Answer
The function of right ventricle is to pump the deoxygenated blood into the lungs for purification. This process mainly depends on the pulmonary vascular resistance. So when there is increased edema surrounding the lungs due to heart failure, there is increased pulmonary vascular resistance in the lungs, so the right ventricle works harder to pump the blood, it slowly results in Right heart enlargement or cardiomegaly.
The pulmonary systolic pressure is increased as a result it is very difficult in exchanging the gases at alveoli due to increased resistance.
To compensate this there is increase in the Respiratory rate which is regulated by Chemoreceptors in brain.
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