Luna Sorian is a 48-year-old woman with alcohol-induced cardiomyopathy. Her most recent left ventricular ejection fraction (LVEF) is 20%. Luna’s daily activities are limited by dyspnea and fatigue. Luna’s medications include:
Luna has been stable on these doses for the past month. Her most recent laboratory results include:
Luna’s vital signs today include blood pressure (BP) of 112/70 mm Hg and heart rate (HR) at 68 beats/minute (bpm). Her lung examination is clear.
After carefully reading the scenario, respond to the following two-part assignment:
Part A: Of the following options provided, explain which is the best approach for maximizing the management of Luna’s heart failure (HF), and why the others would not be an ideal therapeutic change at this time. Please use the textbook, along with appropriate clinical guidelines for heart failure, and/or primary literature articles as needed to formulate your response.
Part B: Luna’s therapy is optimized based on your recommendation for Part A. Her case illustrates an important distinction between medication selection and dosing for heart failure and other cardiac conditions. Explain the major differences when choosing and titrating doses in HF versus hypertension.
To view the assignment rubric for this course, please go to My Grades in your course menu. Locate the assignment in the list and select View Rubric.
Assessment Task 2 –Case Study Weighting: 40% Word count: 1600 words (every question has a specific word count, which must be adhered to) Instructions:
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Case Study 1
Mrs Sharon McKenzie is a 77 year old female who has presented to the emergency department with increasing shortness of breath, swollen ankles, mild nausea and dizziness. She has a past history of MI at age 65. During your assessment Mrs McKenzie reports the shortness of breath has been ongoing for the last 7 days, and worsens when she does her gardening and goes for a walk with her husband.
On examination her blood pressure was 170/110 mmHg, HR 54 bpm, respiratory rate of 30 bpm with inspiratory crackles at both lung bases, and Sp02 at 92% on RA. Her fingers are cool to touch with a capillary refill of 1-2 seconds. Mrs McKenzie states that this is normal and she always has to wear bed socks as Mr McKenzie complains about her cold feet.
Her current medications include: digoxin 250mcg daily, frusemide 40mg BD, enalapril 5mg daily, warfarin 4mg daily but she sometimes forgets to take all of her medications.
The following blood tests were ordered: a full blood count (FBC), urea electrolytes and creatinine (UEC), liver function tests (LFT), digoxin test, CK and Troponin. Her potassium level is 2.5mmol/L.
Mrs McKenzie also has an ECG which showed sinus bradycardia, and a chest x-ray showing cardiac enlargement and lower-lobe infiltrates.
Impression: Congestive cardiac failure
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Case Study 2
Ms Maureen Smith is a 24 year old female who presented to her GP for ongoing gastrointestinal bleeding, abdominal pain and fatigue which has been worsening, and was referred to the local hospital for further investigation.
Maureen was diagnosed with rheumatoid arthritis (RA) when she was 15 years old, and has experienced multiple exacerbations of RA which have required the use of high dose corticosteroids. She is currently taking 50mg of prednisolone daily, and has been taking this dose since her last exacerbation 2 months ago.
Maureen also has type 2 diabetes which is managed with metformin. She is currently studying nursing at university and works part-time at the local pizza restaurant.
On assessment, Maureen’s vital signs are: PR 88 bpm; RR 18 bpm; BP 154/106 mmHg; Temp 36.9oC: SpO2 99% on room air. She has a body mass index (BMI) of 28kg/m2 and the fat is mainly distributed around her abdominal area, as well as a hump between her shoulders.
Maureen’s husband notes that her face has become more round over the past few weeks. Her fasting BGL is 14.0mmol/L. Blood test results show low cortisol and ACTH levels, and high levels of low density lipoprotein cholesterol. She is awaiting a bone mineral density test this afternoon, and is currently collecting urine for a 24-hour cortisol level measurement.
Impression: Cushing’s syndrome
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Case study 3
Mr Nathan James is a 48 year old male who was admitted to the high dependency unit for investigation of jaundice and ascites. He is an interstate truck driver and is married with 2 children. Mr James is a current smoker and known to consume 2 of beer per day. He has a previous (15 years ago) history of recreational drug use and was diagnosed with Hepatitis C 10 years ago.
On assessment:
Mr James is lethargic but orientated to time, place and person and slightly irritable. He is slightly tachypnoeic with moderate use of accessory muscles. His wife reported that Mr James has been spitting blood stained sputum for the last few weeks with no associated cough or shortness of breath. Mr James reports that he has lost 9 kilos in weight which he attributed simply to a lack of appetite. No changes were reported with his urine output. On examination his sclera is mildly jaundiced and has some “unexplained” bruises on his arms and legs. His abdomen is tight and distended and pitting oedema noted on his ankles.
Observations: BP: 115/60mmHg, HR: 110 bpm, RR: 24 bpm, SpO2: 88% on RA, 95% on 6L via Hudson Mask, Temp: 37.8C
Impression: Liver Cirrhosis
Laboratory Findings:
Result | Normal Values | |
RBC | 4.0 million/mm3 | 2.6 to 5.9 million/mm3 |
WBC | 3500/mm3 | 4300 to 10800/mm3 |
Platelets | 75000/mm3 | 150000 to 350000/mm3 |
Serum Ammonia | 110 μm/dl | 35 to 65 μm/dl |
Total Bilirubin | 4.9 mcg/dl | 0.1 to 1.0 mcg/dl |
Sodium | 150 mEq/L | 135 to 145 mEq/L |
Potassium | 3.4 mEq/L | 3.7 to 5.5 mEq/L |
Haemoglobin | 85 g/L | 120-170 g/L |
Albumin | 24 g/L | 35-50 g/L |
Liver Enzymes | Slightly elevated | |
BUN | 22 mg/dl | 7-18 mg/dl |
Creatinine | 154 ml/min | 88 to 137 ml/min |
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