A 68 y/o male diagnosed with congestive heart failure presents to his physician
ID: 3476469 • Letter: A
Question
A 68 y/o male diagnosed with congestive heart failure presents to his physician with distended jugulars and pitting edema of the ankles. His breathing is rapid (20 breaths/min) and pulmonary rales (crackles) are heard bilaterally in the lower lobes of the lungs. He has a pulse rate of 110 beats/min and a BP of 140/88. Blood work shows:
Blood
Values
Urine
Values
Na+ (mEq/L)
128
Na+ (mEq/L)
110
K+ (mEq/L)
3.9
K+ (mEq/L)
80
Mg2+ (mg/dL)
1.7
Mg2+ (mg/day)
19
Ca2+ (mg/dL)
8.9
Ca2+ (mg/day)
105
HCO3 (mEq/L)
30
HCO3
1.7
Creatinine (mg/dl)
1.7
Creatinine (mg/L)
2080
PAH (mg/ml)
0.013
PAH (mg/ml)
5.91
Glucose (mg/dL)
85
Glucose
0
BUN (mg/dL)
14
24hr volume (L)
1.2
pCO2 (mmHg)
45
Osmolarity (mOsm/L)
750
pH
7.31
pH
6.8
How to treat the Px to remove the excess fluid from his body? What would be his final serum osmolality after treatment? Would this alter his blood pressure and why? Ultimately, would this treatment cure the Px? Why? Explain. (use cellular mechanisms and diagrams)
Blood
Values
Urine
Values
Na+ (mEq/L)
128
Na+ (mEq/L)
110
K+ (mEq/L)
3.9
K+ (mEq/L)
80
Mg2+ (mg/dL)
1.7
Mg2+ (mg/day)
19
Ca2+ (mg/dL)
8.9
Ca2+ (mg/day)
105
HCO3 (mEq/L)
30
HCO3
1.7
Creatinine (mg/dl)
1.7
Creatinine (mg/L)
2080
PAH (mg/ml)
0.013
PAH (mg/ml)
5.91
Glucose (mg/dL)
85
Glucose
0
BUN (mg/dL)
14
24hr volume (L)
1.2
pCO2 (mmHg)
45
Osmolarity (mOsm/L)
750
pH
7.31
pH
6.8
Explanation / Answer
1. The excess fluid in this patient can be removed by drugs such as LOOP DIURETICS and ACE INHIBITORS.
2. After treatment his final serum osmolality should be around 285 mOsm.
3. Bringing osmolality back to normal means correcting the BLOOD SODIUM levels which is the main determinant of BLOOD PRESSURE. Hence correcting osmslility tends to normalize blood pressure.
4. Diuretics will remove the excess fluid in the form of edema in lower limbs and lungs. Antihypertensive therapy will normalize the patient's blood pressure and other cardiovascular parameters. Hence this treatment will relieve the SYMPTOMS. But if there are some anatomical changes like HYPERTROPHY of heart that is irreversible.
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