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
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.
Upon undertaking a further assessment of Mr Patel you obtain the following new information:
Vital Signs
RR: 28 bpm
Sp02: 94% on 2lt via nasal prongs
BP: 105/82 mmHg
HR: 122bpm
Temp: 36.5oC
Other information
BGL within normal range
GCS 14 - Eye opening - 4; Verbal response - 4; Best motor response - 6
Cardiac assessment
ECG: indicative of atrial fibrillation
Skin is cool and clammy
Fluid status assessment
Peripheral pulses difficult to palpate
Presence of pitting oedema bilaterally
Capillary refill - 5 seconds
Raised JVP
Output since midnight: 150ml
Abdominal assessment
Abdomen soft and non-tender.
Bowel sounds present.
Respiratory assessment
Bibasilar posterior crackles
Reduced breath sounds in the bases of both lungs
Increased work of breathing
Patient producing pink-tinged frothy sputum
QUESTION:
Rupinder experienced two AMIs which led to congestive cardiac failure. As part of his treatment, he was prescribed diuretics. Explain the pathophysiological reasons why Rupinder had a low urine output prior to the administration of his charted oral diuretics.
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