69263 – Mr Rupinder Patel is a 70 year old retired businessman.

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Mr Rupinder Patel is a 70 year old retired businessman. He has a past medical history of Congestive Cardiac Failure (CCF). This developed after he experienced a two myocardial infarctions 8 years ago. Both ventricles were affected.The death of his wife 2 years ago has led to Rupinder experiencing several episodes of depression which has been exacerbated by his sons both moving to Western Australia for work. The loneliness and sadness makes it difficult for him to be concordant with his CCF management and sustain the necessary lifestyle adjustments required to prevent exacerbations. This has resulted in several admissions to hospital for management and review of his CCF.For this current admission, Mr Patel was referred to hospital by his Nurse Practitioner, after recently rapidly gaining weight (currently 110kg), since his previous visit.The time now is 0800 and you have just come on for your morning shift. Mr Patel has been on the ward for only two hours after spending approximately 12 hours in emergency waiting for a bed to become available.Rupinder appears slightly disoriented. He tells you that he has spent the night in the recliner chair beside the bed, sitting upright because ‘this is the only way I can get my breath’. He tells you he feels terribly tired.You observe that the 1 litre water jug that he has been drinking from, since coming to the ward, is nearly empty.Collect cuesYou review the following documentation:• Referral letter (docx, 13.5KB)• ADDS chart (pdf, 452.7KB)• Medication chart (pdf, 966.5KB)• Fluid balance charts (pdf, 187.3KB)• Progress notes (docx, 34KB)Upon undertaking a further assessment of Mr Patel you obtain the following new information:Vital SignsRR: 28 bpmSp02: 94% on 2lt via nasal prongsBP: 105/82 mmHgHR: 122bpmTemp: 36.5oCOther informationBGL within normal rangeGCS 14 – Eye opening – 4; Verbal response – 4; Best motor response – 6Cardiac assessmentECG: indicative of atrial fibrillationSkin is cool and clammyFluid status assessmentPeripheral pulses difficult to palpatePresence of pitting oedema bilaterallyCapillary refill – 5 secondsRaised JVPOutput since midnight: 150mlAbdominal assessmentAbdomen soft and non-tender.Bowel sounds present.Respiratory assessmentBibasilar posterior cracklesReduced breath sounds in the bases of both lungsIncreased work of breathingPatient producing pink-tinged frothy sputumQuestion 1Describe the pathophysiological mechanisms for Rupinder’s presentation of -pink-tinged frothy sputum-. Identify any other data which supports your explanation.Word limit: 200 words excluding in-text references.Question 2Relating to Rupinder’s past and present medical history, explain the rationale for why he was prescribed spironolactone, and describe what evidence would indicate that this therapy was effective for Rupinder.Word limit: 200 words excluding in-text references.

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