Clinical Scenario
Mr. Robert (Bobby) Holden is a 62-year-old gentleman of Jardwadjali background who works as a mechanic. Mr Holden is married to Sandra, and they have four children and ten grandchildren, all of whom live in Melbourne. Bobby and Sandra live in their rented house in Sunshine; they receive no home help or community supports.
Mr Holden has a past medical history of Rheumatic Heart Disease and associated Mitral Stenosis, Hypertension, Gastro Oesophageal Reflux Disease, and Type Two Diabetes Mellitus. Mr Holden is currently waiting an outpatient appointment with Mr William’s cardiothoracic team for review and scheduling of a degenerative MR repair.
Mr Holden is adherent to his medical management plan and acts as a mentor to newly diagnosed indigenous patients with Diabetes at VAHS Minajalku. He has no allergies and is an ex-smoker (44 pack years). Mr Holden drinks “two to three” VBs each night after dinner. Mr Holden last presentation to Ritz Medical Centre was over 12 months ago for dressings to a wound on the planta aspect of his left foot.
Over the last few days, Mr Holden has been very disheartened over the change in his health status. Recently, he has been getting increasing episodes of shortness of breath with minimal physical activity and orthopnoea (currently sleeping on three pillows). At times, he has also been experiencing paroxysmal palpitations and chest pain. The episodes of chest pain and palpitations quickly settle once he catches his breath and stops what he is doing and sits down. He has also been complaining to Sandra of increased general malaise for the last 3 – 4 days and a dry irritating cough. Unfortunately, his malaise has not been helped by a recent weight gain of 5kg and increased episodes of nocturia.
On Thursday, Mr Holden presented to the Ritz Medical Centre Emergency Department via Ambulance, with acute onset (< 1 hour) of chest pain and palpitations. You are currently undertaking your PEP rotation at the Ritz Medical Centre Emergency Department and after you have received an ISBAR handover from the Paramedic, you begin your primary and secondary assessment of Mr Holden.
During your head to toe assessment of Mr Holden, he complains to you of having a funny feeling in his chest. You palpate Mr Holden’s pulse and note that it is irregular, with a rate of 125 beats per minute. You quickly look up at the ECG monitor and see the following rhythm.
You notice that Mr Holden has tachypnoea. His extremities are cool to touch and his jugular vein appears to be distended. You auscultate Mr Holden’s anterior chest and note low pitched, bubbling, moist sounds that persist from early inspiration to early expiration. Posteriorly there is dullness to percussion and reduced air entry in the lower lobes bilaterally. Mr Holden has abnormal heart sounds, which you think is a diastolic murmur, and bilateral pitting oedema to above his knees. His vital signs are
GCS: 15 (E4, V5, M6) Mr Holden appears distressed and anxious
PR: 126 bpm, irregular
RR: 32 breaths/min, labored
BP: 175/95 mmHg
SpO2: poor quality tracking but current 89% on 6l oxygen via Hudson mask
Your buddy nurse (Susan), thinks that these assessment findings point towards acute pulmonary oedema, and states to you that Mr Holden will need several tests to confirm this diagnosis. As per the medical orders, Susan quickly begins collecting and organising the tests requested e.g. arterial blood gas analysis (ABG), the 12-lead electrocardiogram (ECG), full blood examination (FBE), urea and electrolytes (U &Es), estimated glomerular filtration rate (eGFR), cardiac enzymes, B-type natriuretic peptide (BNP) and N-terminal-pro-BNP (NT-pro-BNP), blood glucose level (BGL), and chest X-ray (CXR). The treating Medical Officer, Dr Ford, states to Susan that “we need to get this sorted quickly, can you begin pharmacological treatment as per the Ritz Protocol for Acute Pulmonary Oedema, STAT!”
Pathophysiology:
- a) There are numerous causes of heart What do you think is the likely cause of Mr Holden’s clinical
deterioration? Provide a scientific rationale for your answer.
- b) Mr Holden presents with several classical signs and symptoms of heart failure. Select two (2) of these classical signs and symptoms and discuss their underlying pathophysiology. Be sure to relate your answer to the case study.
Investigations;
- a) Dr Ford has ordered several investigations. Select two (2) investigations identified and provide a scientific rationale and justification for the investigations selected. In addition, describe the investigative findings that would support a diagnosis of heart failure in Mr Holden.
Pharmacology:
- a) Acute pulmonaryoedema is a medical emergency which requires immediate The goals of therapy are to improve oxygenation, maintain an adequate blood pressure for perfusion of vital organs, and reduce excess extracellular fluid. Discuss one (1) pharmacological intervention that will be implemented in the management of Mr Holden’s Acute pulmonary oedema (Oxygen therapy is not to be discussed). Provide a scientific rationale for the selected intervention and discuss the therapeutic benefit of the pharmacological treatment selected.