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Case Scenario

Russell is a truck driver aged 68 years whos admitted to Monash Health with breathlessness.

History Of Presenting Complaints

He describes progressive dyspnoea that he has had for the past three months and is now breathless when showering and dressing. For the past week, he has felt more comfortable overnight sleeping on three pillows. He denies any chest pain. You have taken Russell’s history and vitals and made a Med call to review Russell.

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Past Medical History

Russell says he had a heart attack 15 years ago, which was treated with a stent, and has had no chest

pain since then.

Russell has Chronic Obstructive Pulmonary Disease (COPD) for the past 30 years.

He also has had problems with high blood pressure, diabetes and cholesterol.

Medication History

His medications are as following –

1.Aspirin 100mg oral daily,

2.Salbutamol 2 – 4 puffs PRN

3.Budesonide/Efomoterol fumarate dehydrate 2 puffs daily

4.Perindopril 5 mg in the morning daily

5.Atenolol 50 mg daily in the morning

6.Metformin 500mg oral BD

7.Atorvastatin 40 mg daily. Russell is married and has two children. He used to smoke 20 cigarettes per day since he was 18 years old, but stopped smoking when he had his heart attack. He drinks a small amount of alcohol.

Russell is married and has two children. He used to smoke 20 cigarettes per day since he was 18 years old, but stopped smoking when he had his heart attack. He drinks a small amount of alcohol.

Observation/On Examination

On examination his

1.Heart rate (HR) is 90 bpm and regular

2.Blood pressure (BP) is 150/90 mmHg

3.Jugular venous pressure (JVP) is slightly elevated

4.He has mild oedema in his both legs

5.BMI 26 m2/kg

6.Skin – sweaty and pale

7.RR 26, regular

8.SpO2 94% RA

9.Temp. 37o C

10.BSL 5.5

Duty doctor examined him and confirmed Russell develop heart failure. He orders some laboratory investigations, CXR and Echocardiogram, 2L oxygen, Tab Frusemide 40 mg in the morning and Tab Spironolactone 25 mg orally once a day.

Biochemistry Results Are:

1.Na 135 mmol/L [134 to 145 mmol/L]

2.K 4.2 mmol/L [3.5 to 5.0 mmol/L]

3.Urea 8.9 mmol/L; [2.5 to 7.1 mmol/L]

4.Creatinine 98 μmol/L [53 to 106 μmol/L]

5.Total cholesterol (TC) 6.8 mmol/l, [<5.5 mmol/L]

6.Low density lipoprotein (LDL) 5.0 mmol/L [2.0 mmol/L]

7.High density lipoprotein (HDL) 1.0 mmol/L [> 1.0mmol/L]

8.Triglycerides (TG) 2.1 mmol/L [< 2.0 mmol/L]

Full Blood Count Is Normal

Chest X-ray-A chest X-ray shows an increased cardiothoracic ratio (dilated heart) and obliteration (not visible) of cardiophrenic and costophrenic angles in the lung fields suggestive of pulmonary oedema and heart failure

Echocardiogram shows a dilated left ventricle with severe systolic dysfunction (left ventricular ejection fraction (LVEF) 25%. Russell’s dyspnoea improves with Frusemide and Spironolactone

Case Scenario Questions

1.Discuss risk factors that contributed to Russell developing heart failure.

2.Describe pathophysiology of right and left sided heart failure using clinical presentation and examination findings of Russell Russell has long history of COPD.

3.Explain the term ‘acute exacerbation of COPD’  What factors put patients like Russell at high risk for exacerbations of COPD?

4.Use the table below (or something similar) to discuss the following drugs: