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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 cues You review the following documentation: • Refe

rral 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 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 1 Describe 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 2 Relating 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.