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Case 1 K.H. is a 67-year-old African-American man with primary hypertension and diabetes mellitus. He is currently taking an angiotensin-converting enzyme (ACE) inhibitor and following a salt-restricted weight loss diet. He is about 30 pounds over his ideal weight. At his clinic visit his blood pressure is noted to be 135/96. His heart rate is 70 beats/min. He has no complaints. His wife brought a blood pressure cuff and stethoscope with her in the hope of learning to take her husband's blood pressure at home. Discussion Questions 1. What risk factors for primary hypertension are evident from K.H.'s history and physical data? 2. What is the rationale for treating K.H. with an ACE inhibitor? What is the mechanism of action? What part of the blood pressure formula do they affect? 3. K.H.'s hypertension is not adequately controlled. What other intervention might be considered? 4. What tips can you give K.H.'s wife to improve the accuracy of her blood pressure measurement technique? Case 2 A.O. is an 89-year-old woman with a long history of systolic heart failure secondary to a large left ventricular infarct when she was in her 70s. She had poor activity tolerance and required assistance with activities of daily living. Even minimal activity was associated with moderately severe dyspnea and exertional chest pain, which was relieved by rest. A.O. also exhibited marked pedal edema bilaterally. She is being treated with digitalis, furosemide (Lasix), KCl, and sublingual nitroglycerin. Discussion Questions 1. Which type of heart failure (left or right sided) is usually associated with dyspnea? What other clinical findings are likely to be present with left-sided heart failure? 2. What compensatory mechanisms are likely to be operative in A.O. to enhance cardiac output? 3. What is the most likely cause of A.O.'s pedal edema? 4. What is the cause of A.O.'s exertional chest pain? What laboratory tests would be useful to confirm this diagnosis? 5. What is the rationale for the use of each of A.O.'s medications in managing her heart disease? Case 3 C.C. is a previously healthy 27-year-old man admitted to the critical care unit after an accident in which he was hit by a car and dragged along the pavement for nearly 100 feet. He suffered a frontal contusion, fractured clavicle and ribs, and extensive abrasions on his arms, legs, side, back, and buttocks. On admission, he was tachycardic, hypotensive, unresponsive, and ventilating poorly. He was placed on a mechanical ventilator and given IV fluids for the treatment of his shock. C.C. responded well to fluids, with an increase in blood pressure and an improvement in urine output. Discussion Questions 1. Based on his case history and responsiveness to fluid therapy, what type of shock was C.C. experiencing? 2. What other clinical findings would be helpful in confirming the type of shock? Why? 3. Because of his many open wounds and invasive lines, C.C. is at risk for sepsis and septic shock. What clinical findings would suggest that this complication has developed? **Need all references if have**