Mrs. Brunner is an 84 year you are taking care of in a nursing home.

Mrs. Brunner is an 84 year you are taking care of in a nursing home. She developed a pressure ulcer during her hospitalization for a recent left total hip replacement. She complains she is not feeling well today and thinks she is “coming down with a cold.” She has a nonproductive cough with increased shortness of breath for the past 2 days and has needed to sleep in her recliner because she is uncomfortable lying in her bed. Her appetite is poor, which she attributes to the fact that she has been constipated from pain medication she was prescribed after surgery. Over the past few days, she has only been taking chicken and beef broth for her meals due to her upset stomach. Normally, Mrs. Brunner is able to walk up and down her hall with the physical therapist without difficulty, but yesterday she could only walk about 10 feet before needing to rest due to shortness of breath.

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Her past medical history includes the following:

• CAD with myocardial infarction (MI) in 2007

• Congestive heart failure (CHF)

• Osteoarthritis of hips s/p L hip replacement

• Hypertension (HTN)

• Hypercholesterolemia

Meds:

• Lopressor 25 mg po bid

• Lasix 40 mg every morning

• KDur – 20 meq every morning

• Prinivil 10 mg q morning

• Vicodin (acetaminophen/hydrocodone) 500/5 mg I po tid

• Aspirin 81 mg po daily

• Zocor 20 mg po q hs

• Advil 400 mg pot id prn

Immunizations: seasonal flu shot: Nov 2018, all others uptodate.

Physical Exam:

VS: BP 110/62, pulse 102, respirations 22; O2 sat 92%

Heart sounds: S1S2 regular with S3 gallop, no murmurs or rubs

Lung sounds: respirations regular, lungs essentially clear with basilar crackles

Abdomen: soft, nontender, distended with positive hepatojugular reflex, active bowel sounds auscultated in all 4 quadrants

Extremities: 2+ edema in bilateral legs to knees, capillary refill < 2 seconds

Questions:

1) What do you expect may be causing Mrs. Brunner’s symptoms?

2) What are the pertinent positive findings on your physical exam that justify your conclusion?

3) Explain the pathophysiology of these findings.

4) What may have precipitated this problem?

5) What diagnostic tests should be conducted to confirm your diagnosis and what is the purpose of these tests?

6) How can you help Mrs. Brunner to prevent future CHF exacerbations?

Expert Answer

1. Congestive heart failure exacerbation causing Mrs Brunner the mentioned symptoms. 2. The patient is having increased pulse rate of 102, normal S1S2 but with S3 gallop and peripheral oedema. This indicates that the patient is having Cong…

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