68 y/o male who had an MI in April, 2015 was seen by his physician on Aug. 30, 2
ID: 3483048 • 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.
What is the cause of the arrhythmia seen in the ECG? The attending physician give the Px propranolol. Why and how would this affect the heart at both tissue and cellular levels? Would this drug have an effect on respiration?
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 cause of arrhythmia in the patient includes injury from previous heart attack and change in heart muscle.
The prominent Q wave in lead aVR is related to wall motion abnormality in right ventricle region.
The propanolol will prevent heart attack,hypertension and high blood pressure by preventing cytosolic sodium overload which affect the mitochondrial production of ATP.
Propanolol should not be taken if the patient suffers from asthma.
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