Howard is a 77 year-old retired car salesman. He was brought to the local emerge
ID: 3479931 • Letter: H
Question
Howard is a 77 year-old retired car salesman. He was brought to the local emergency department (ED) following complaints of shortness of breath after taking a Benadryl “to help me sleep”. He states that he has a history of “heart troubles”, has smoked cigarettes for “over 40 years” and generally tries to “avoid the doctor when I can”. You review his medical history from a previous admission and note that he has been previously diagnosed with heart failure, COPD, dyslipidemia and nicotine dependence. He did not bring a list of his medications with him to the ED.
His dyspnea responded to oxygen, an inhaled Beta-2 agonist (albuterol), and inhaled Atrovent (ipratropium bromide), a short-acting anticholinergic drug. His arterial blood gas values (ABGs) on admission are as follows:
Test
Value
Normal Range
PaO2
55 mmHg
75-100 mmHg
SaO2
88%
94-98%
PaCO2
46 mmHg
35-45 mmHg
pH
7.3
7.35-7.45
HCO3
30
22-26 mEq/L
On physical you notice that he has 4+ “pitting edema” (pedal edema).
His ECG shown below indicates that he has left ventricular hypertrophy. An echocardiogram confirmed that he has concentric left ventricular hypertrophy and a ventricular ejection fraction (EF) of 50%.
Howard is given furosemide (Lasix), a diuretic medication that reduces water and sodium reabsorption from the loop of Henle. It is used for patients with left-sided heart failure.
You look in on Howard and notice that he appears a bit uncomfortable. When asked how he is feeling, he states, “I feel okay but I am having trouble urinating and have pain in my lower stomach.” You instruct the nurse to go ahead and catheterize Howard with a Foley catheter and urine begins to flow into the catheter bag. He states, “Usually, I have to go all the time but lately when I go, it starts and then stops and it feels like I just can’t empty all the way. I don’t like this catheter thing but it sure helps relieve the pain. Later that day you give Howard a digital rectal exam (DRE) and draw blood for a prostate specific antigen (PSA) blood test. Upon viewing the results of this blood test, you tell Howard that he has benign prostatic hypertrophy (BPH).
BI 240 Path Case Study 4: Cardio-Resp. Questions Name: ______________________
What is COPD? What are the symptoms? What causes it?
How are chronic bronchitis and emphysema related to COPD?
An agonist drug binds to the drug receptor and mimics the actions of an endogenous substance (naturally occurring in the body). Where are the beta 2 receptors in the body and what is the endogenous substance that binds to them? What happens as a result?
Anticholinergic drugs bind to cholinergic receptors. Acetylcholine is the endogenous substance that binds to cholinergic receptors. But inflammatory mediators (histamine, bradykinin, eicosanoids) also stimulate cholingergic receptors. What happens when cholinergic receptors are stimulated in the airways? Why would oral anticholinergic drugs such as the over-the-counter (OTC) antihistamine diphenhydramine (Benadryl) be dangerous for a patient with COPD but inhaled anticholinergic drugs such as Atrovent (ipratropium)be beneficial?
What do the arterial blood gas values suggest?
What causes left-sided heart failure? What symptoms of heart failure does Howard have?
Lasix is a diuretic medication that reduces water reabsorption from the loop of Henle. It is used with patient who have left-sided heart failure. Why would a diuretic affecting the loop of Henle help Howard?
How does a Foley catheter work?
What are the symptoms of benign prostatic hyperplasia (BPH)? What causes it?
Test
Value
Normal Range
PaO2
55 mmHg
75-100 mmHg
SaO2
88%
94-98%
PaCO2
46 mmHg
35-45 mmHg
pH
7.3
7.35-7.45
HCO3
30
22-26 mEq/L
Explanation / Answer
COPD is chronic obstructive pulmonary disease. It causes obstruction in airflow from the lungs. The symptoms include difficulty in breathing, cough, wheezing and excessive production of sputum or mucous. It is caused by long term or chronic exposure to irritants such as nicotine.
Chronic bronchitis is inflammation in the lining of bronchial tubes. Emphysema is dilatation of alveoar sac. Both of these are components of COPD.
Beta 2 receptors are located in bronchioles of the lung and blood vessels of skeletal muscles. Adrenaline binds to beta 2 receptors causing dilatation of bronchioles. Stimulation of cholinergic receptors in airways cause broncho constriction.
Over the counter antihistamines may cause drowsiness but inhaled anticholinergics cause less ststemic side effects. So, inhaled drugs are preferred over oral drugs in patients with COPD.
The arterial blood gas analysis suggests that there is respiratory acidosis with compensated metabolic alkalosis. The oxygen saturation is below normal.
Pulmonary congestion in COPD will lead to left sided heart failure. Symptoms include breathlessness, cough, wheezing, cyanosis, confusion. Lasix by excreting water decreases the plasma volume. This reduces pulmonary congestion and the symptoms get releived.
Foley's catheter is placed in urinary bladder to drain urine. BPH causes difficulty in urination, frequent urination and obstruction to the flow of urine. It is caused by enlargement of prostrate gland pressing upon the urethra.
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