CASE STUDY:
Mrs. F., a 56 year old Caucasian woman, was admitted to the Cardiac Step-Down unit with complaints of increasing shortness of breath on exertion, weight gain of 10 pounds in the last month, and difficulty sleeping without sitting straight up on three pillows.

History:
CABG X 2 with aortic value replacement in 1991, mitral valve regurgitation, HTN, CHF, hyperlipidemia, Type II DM, asthma, DJD, anxiety, and recently diagnosed with sleep apnea following 3 sleep studies with a CPAP prescribed at HS.
Mrs. F. works as a cosmetologist instructor. She states she has been unable to walk across the school campus without stopping several times to “catch her breath”. She states she has faithfully been taking her medications. She has not been sick or around anyone with any type of infection recently.

Assessment:
Neurological- able to follow commands, moves all extremities without difficulty, A&OX3.
Respiratory-Lungs sounds are diminished in all lobes both anteriorly and posteriorly. No wheezing or crackles present. Respirations are 20 with noted use of accessory muscles. SATs are 96% on 4L of O2 via nasal cannula.
Cardiovascular-Heart rate is regularly-irregular at 65 bpm. Telemetry monitor shows NSR with controlled a fib. Trace pitting edema in noted bilaterally in the lower extremities.
GI-Patient is obese. Abdomen is slightly distended. Last BM was this am. A cardiac, 1800 ADA diet is prescribed.
GU-Patient voids clear yellow urine without difficulty or pain. She is continent and uses the BSC.
Musculoskeletal-Patient is ambulatory. Gets OOB to chair without assistance.
Integumentary-Patient has bruising to bilateral upper extremities, states “related to numerous venipuntures”. Puncture sight to right groin from previous cardiac cath, area has no drainage, soft to palpation without a hematoma. Skin is dry and mildly cool to touch.

Diagnostics/Procedures:
CXR-cardiomegaly
ECHO-biatrial enlargement, notes prosthetic aortic valve
TEE with possible cardioversion scheduled for next day

Lab Values:
BNP 805.9 (norm 0-125), PT/INR 15.1/1.2, Troponin (-) X 3, CK total 39, Na+ 134, K+ 3.4, BUN 17, creatinine 0.5, Hgb 13.4, Hct 41.5, Platelets 309, WBC 9.7

Medications:
Potassium Chloride 20mEq PO q 4 hours
Coumadin 10mg PO daily
Lovenox 130mg SBQ q 12 hours
Metroprolol 50mg PO BID
Lasix 40mg IVP BID
Crestor 10mg PO daily
Accu check AC/HS with sliding scale Regular insulin coverage
Novolin 70/30 50 units SBQ with breakfast

Questions:
What is the significance of the finding of the CXR and ECHO?
Why would a TEE with possible cardioversion be scheduled?
Why are Coumadin and Lovenox prescribed?
Which lab values are significant for diagnosis?
Which lab values are of importance for TEE consideration?