Question

Case Study

Amnah is a 55-year-old female patient who has been admitted to the medical ward with acute shortness of breath, chesty cough, wheezing and chest discomfort. Amnah’s vital signs were: SpO2 82% on room air, BP 150/90 mmHg, Pulse 110 beats/min, RR 28 breaths/min, and Temperature 38.7 °C. Amnah has a history of COPD and hypertension for 15 years. She was also diagnosed with heart failure 2 years ago. While doing the physical examination, the patient seemed to use her accessory muscles and have cyanosis in the lips and nose. She also started to get mixed up during the nursing assessment as she could not figure out that she was in the hospital. Amnah also complaint of weakness and fatigue and her lower limbs were very edematous. After a medical review, ABG was taken, CXR was done and venous blood samples were sent for complete blood count, chemistry and culture and sensitivity. Amnah’s lab results were as follows:

Chemistry	Patient Value	Normal Values	ABG & CXR
Sodium	148	136-146 mmol/L	pH 7.25 PaO2 49mm Hg PaCo2 58mm Hg HCO3 27mEq/L
Potassium	4.4	3.5-5.3 mmol/L
Chloride	106	98-108 mmol/L
BUN	68	7-22 mg/dl
Creatinine	1.66	0.7-1.5 mg/dl
Blood culture and sensitivity	streptococcus pneumoniae		CXR: opacity of right lower loop with consolidation and pleural effusions with cardiomegaly
Calcium	7.8	8.9-10.3 mg/dl
Phosphorus	10.4	2.6-6.4 mg/dl
Alkaline Phosphatase	321	30-110 IU/L
Hemoglobin	14.5	14-17 gm/dl

Based on the medical review and the diagnostic tests results, Amnah was mainly diagnosed with impaired respiratory functions. She was also found to have some cardiac and renal abnormalities. The doctor ordered immediate treatment and requested very close monitoring of Amnah.

1. Amnah’s doctor has commenced her on immediate treatments. Give five types of the medical treatments that could benefit Amnah?

Answer 1

Answer :

The case discussed above is a known case of Chronic obstructive pulmonary disease(COPD) and hypertension, presenting with acute onset of breathlessness , cough , wheezing and chest discomfort.

Examination revealed : Tachypnea, Tachycardia, Fever and elevated Blood pressure.

The patient has developed altered sensorium ,and cyanosis in addition to the above clinical features (suggests impending respiratory failure)..

Investigations revealed the following : -

ABG : suggestive of Respiratory acidosis

Renal function tests : Blood Urea Nitrogen and Creatinine are raised, suggesting renal impairment.

Low calcium and raised phosphorus levels

Blood culture : Streptococcus pneumoniae

Chest X ray : Opacity of right lower lobe with consolidation and pleural effusions with cardiomegaly

Suggestive of Pneumonia & Heart failure.

From the information given above , the diagnosis is

COPD / Hypertension / Right lower lobe pnuemonia- caused by streptococcus pneumonia / Congestive heart failure /Renal dysfunction /  Impending respiratory failure.

Here the primary problem is pneumonia, whch could have also precipitated a heart failure.

Heart failure may be  precipitated or aggravated by Hyperdynamic states (fever, thyrotoxicosis), Hypoxia , Infections, Anemia, Arrhythmias , and electrolyte imbalances.

Treatment :-

Since the patient is going in for respiratory failure , she must be admitted in intensive care unit, and monitored very closely.

1) Propped-up position or sitting position with legs hanging down helps to reduce venous return.
2) Oxygen inhalation : 100% oxygen, preferably under positive pressure. Oxygen corrects hypoxia· and positive pressure raises intraalveolar pressure reducing transudation of fluid.
Non-invasive ventilation (NIV ) may be tried if oxygen saturation remains below 90%.

NIV can be provided by either CPAP (continuous positive airway pressure) or bilevel ventilation (both inspiratory and expiratory support, BiPAP).

3) Intravenous loop diuretics,: Furosemide 40-100 mg (drug of choice), ethacrynic acid 40-100 mg or bumetanide 1 mg may be given.
Diuretics reduce the circulating blood volume and hasten the relief of pulmonary oedema.
Intravenous furosernide has a venodilator action by which it reduces venous return. This effect occurs within a few minutes while diuresis may take 30 minutes.

Correction of precipitating causes of heart failure .

Infections , arrhythmias, increased metabolic rate as in fever, thyrotoxicosis are factors that can precipitate or aggravate heart failure.

4) Antibiotics : Intravenous antibiotics should be given , based on the antibiotic sensitivity reports , in order to treat the pneumonia.

5) Antipyretics : As mentioned earlier, fever resuls in a hyperdynamic circulation state, which can precipitate or aggravate heart failure.

Fever is controlled by antipyretics like Paracetamol (Acetaminophen).