Descriptor: BH is a 56-year-old African American female with a past medical history of chronic obstructive pulmonary disorder (COPD), type 2 diabetes mellitus, hyperlipidemia, and NSAID induced peptic ulcer disease (PUD). She was admitted to the ED due to having difficulty breathing.
SUBJECTIVE
CC: “I’ve had trouble breathing these last few days and I can’t stop coughing.”
HPI:
BH is a 56-year-old African American female with a past medical history of chronic obstructive pulmonary disease (COPD), type 2 diabetes mellitus, hyperlipidemia, NSAID induced peptic ulcer disease (PUD) and tobacco use. She was admitted to the ED after reporting having difficulty breathing. Her symptoms began two days ago, and she reports she experienced increased dyspnea, cough,
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sputum, purulence and thick/yellow mucus, but she has not reported a fever. BH was put on 2 L of O2 via a nasal cannula, one dose of IV Azithromycin (Azithromycin) 500 mg, one dose of IV MethylPREDNISolone (Solu-Medrol) 60 mg, and nebulized Ipratropium and Albuterol (DuoNeb). BH had a chest x-ray, and the results showed no signs of acute pneumonia, but it was consistent with her COPD. She has also explained how she takes her cholesterol medication, Atorvastatin (Lipitor) 40 mg oral tablet, every other day because she thought it was causing her leg pain. Her cardiac exam reported to be within normal limits, with no signs of peripheral edema. The patient is taking Enoxaparin (Lovenox) injectable solution for deep vein thrombosis prophylaxis, due to being inactive and in bed during this hospital stay. Finally, regarding the patient’s type 2 diabetes mellitus, she has had it for the past 3 years, and her condition is controlled. PMH/Surgical History: COPD: 01/01/08 – current Type 2 Diabetes Mellitus: 01/01/15 – current Hyperlipidemia: 01/01/15 – current PUD (NSAID Induced): 02/10/18 – current Tobacco Use: 1978 - current FH: Mother is alive at age 78. Has hypertension and type 2 diabetes mellitus. Father died at age 58, due to complications of COPD. SH: Smoking status: Smokes 1 ppd for 40 years. Alcohol use: Denies Illicit drug use: Denies Family: has 3 children (all grown) who live out of state. Marriage status: widowed. Currently lives alone. Medication List: Enoxaparin (Lovenox) 80 mg/0.8 mL injectable solution • Subcutaneous injection every 12 hours [03/28/18 – current] Umeclidinium-Vilanterol (Anoro Ellipta) 62.5 mcg-25 mcg • 1 inhalation once daily [03/27/18 – current] Ipratropium bromide (Atroven HFA) 17 mcg inhaler • 2 inhalations 4 times a daily, as needed [03/27/18 – current] Albuterol-Ipratropium (DuoNeb) 2.5 mg-0.5 mg/3 mL inhalation solution • 1 nebulization every 4-6 hours, as needed[03/27/18 – current] Azithromycin (Azithromycin) 500 mg intravenous powder for injection • 500 mg IV every 24 hours, in the morning [03/27/18 – current] MethylPREDNISolone (Solu-Medrol) 40 mg preservative-free injectable powder for injection • 60 mg IV once daily, in the morning [03/27/18 – current] Metformin (Metformin) 1000 mg oral tablet • 1 tablet twice daily, in the morning and evening [03/27/18 – current] Esomeprazole (Nexium) 40 mg oral delayed release capsule • 1 capsule daily in the morning [03/27/18 – current] Atorvatstatin (Lipitor) 40 mg oral tablet • 1 tablet daily in the morning [date not specified] Herbal/Natural Products: Unknown Immunization History (as per….): Influenza Virus Vaccine (Inactivated Quadrivalent Intramuscular Suspension) • Administered on 11/07/17 Tetanus/Diptheria/Pertussis (Tdap) Adult/adol – 5 units-2 units-15.5 mcg/0.5 mL intramuscular suspension • Administered on 01/07/14 Pneumovax 23 (PPSV 23) Injectable Solution • Administered on 06/01/17 (Childhood vaccinations up to date) Allergy/ADR: NKDA ROS: The patient has trouble breathing. She is experiencing an increase in coughing frequency and sputum production (thick and yellow). Also, she is experiencing increased dyspnea and leg pain. OBJECTIVE Vitals: Taken on 03/28/18 • BP: 140/90 • Pulse: 100 • Respiratory Rate 26 • Temperature: 98.6F Taken on 03/27/18 • BP: 150/90 • Weight: 85 kg PE: None Labs: Taken on 03/27/18 • Bicarb: 30 mEq/L • Cholesterol: 210 mg/dL • LDL: 137 mg/DL • Arterial pH: 7.32 • Arterial O2: 52 • Arterial CO2: 58 Imaging and other diagnostic tests: None ASSESSMENT 1. COPD Exacerbation BH is currently taking Anoro Elipta (1 inhalation daily), DuoNeb (1 inhalation every 4-6 hours, as needed), Azithromycin IV (500 mg IV every 24 hours), and Solu-Medrol IV (60 mg IV once daily). Her condition can be treated as chronic, treated, and not at goal. BH has had trouble with breathing and is experiencing an increase in coughing frequency, sputum production, dyspnea, and purulence. A few of the patient’s lab values are not within normal limits, such as her bicarbonate, arterial pH, arterial O2 and arterial CO2 values, as of 03/27/18. Overall, the goal for the patient is to prevent exacerbations from occurring, relieve these symptoms and support a normal lung function.1 It is also noted that the patient has smoked 1 pack a day for the past 40 years and that she has had COPD for the past 3 years. She is also currently receiving 2 L nasal cannula, which she is currently not wearing, due to her respiratory acidosis. 2. DVT Prophylaxis The patient is currently taking Lovenox 80 mg/0.8 mL injectable solution every 12 hours. This condition can be classified as acute, treated, and not at goal. The patient is on bed rest at the hospital and the patient is receiving too high of a dose of the lovenox.2 The goal for BH is to reduce risk factors that may heighten the chance of a venous thromboembolism (VTE). It is noted that the patient is obese and is currently immobile. 3. Hyperlipidemia BH takes Lipitor 40 mg oral tablet daily for her hyperlipidemia, and her condition can be treated as chronic, treated, and not at goal. As of 03/27/18, her cholesterol and LDL levels are not within normal limits. The patient has been complaining of leg pains and her condition is a result of an adverse drug reaction.3 The goal of therapy is to reduce the patient’s LDL levels to prevent ASCVD risk and to improve the patient’s overall quality of life, while also reducing the patient’s leg pain. It is noted that the patient has diabetes mellitus 2, has an increased BMI, and she is 56 years old. 4. PUD The patient is currently on Nexium 40 mg oral tablet, and she takes it once a day for her PUD. The patient’s condition can be classified as acute, treated, but not at goal. The patient has been experiencing ulcers due to her NSAID use, which she has been using for her statin-induced myalgia. Essentially, the problem is a result of an unnecessary drug therapy. The goal for the patient is to reduce the symptoms of PUD. It is noted that the patient is a heavy NSAID user and has been smoking for the past 40 years. PLAN 1. COPD Exacerbation: Non-drug therapy: Lifestyle changes, such as quitting smoking and exercising. Drug therapy: Discontinue the patient’s DuoNeb and continue taking the Anoro Elipta and Atroven HFA. The patient’s Azithromycin IV medication will be changed to Azithromycin 250 mg oral tablet once daily, for 3 days. Also, the patient’s Solu-Medrol IV medication will be changed to a 32 mg injection, every 4-6 hours. The patient should also continue to use the nasal canulla. Efficacy Monitoring: The patient’s arterial blood gas and bicarbonate levels will continue to be monitored. In addition, the patient’s inhaler technique will also be assessed, to see if the patient is using it correctly. There will be a follow up in one week to make sure the medications are working appropriately. Safety Monitoring: We will monitor the patient’s lung function at home and any changes to the patient’s lab values. In addition, symptoms such as dyspnea, sputum production, and purulence will be monitored. Patient Education: The patient will be educated on proper inhaler use and the importance to adherence of the medications. Collaboration: Inform the patient’s providers about the various prescriptions being discontinued, the changes to some of the prescriptions, and prescriptions being continued. 2. DVT Prophylaxis: Non-drug therapy: The patient should be more active (walking around) and wearing compression socks to allow blood to continue flowing. Drug therapy: Lovenox 80 mg/0.8 mL injectable solution will be lowered to a 40 mg/0.4 mL injectable solution dose. Efficacy Monitoring: The patient’s anti-Xa levels will be monitored to see if the medication is effective. Safety Monitoring: The patient will be assessed for bleeding. In addition, the patient will be assessed for injection site reactions/pain, hyperkalemia, and thrombocyotopenia. Patient Education: It will be mentioned to the patient the side effects of lovenox, specifically with the risks of bleeding. Collaboration: Inform all of the patient’s providers of the dosage change of Lovenox. 3.
Hyperlipidemia:
Non-drug therapy: Lifestyle changes, such as a low fat diet and weight loss, along with more exercise. Also, quitting smoking would be beneficial as a treatment for the patient.
Drug therapy: The patient will discontinue the use of Lipitor and the patient will now be on Rosuvastatin (Crestor) 80 mg oral tablet. The patient will take the prescription daily, at the same time.
Efficacy Monitoring: The patient’s LDL and total cholesterol levels should be monitored.
Safety Monitoring: The patient should continue to monitor her leg pain and also check on her blood glucose levels, CK levels, and LFT.
Patient Education: It will be mentioned how statins may cause muscle pain and to not take any pain relievers for her myalgia, rather contact her provider as it may be due to the statin.
Collaboration: Inform the patient’s providers of the change in the patient’s statin medication.
4. PUD:
Non-drug therapy: The patient should avoid spicy food and excessive alcohol consumption. Also, the patient should avoid the use of NSAIDS.
Drug therapy: Discontinue Nexium because the ulcer will heal by avoiding NSAID use.
Efficacy Monitoring: Monitor for any new formations of ulcers and stomach
pain. Safety Monitoring: Monitor for any GI pain. Patient Education: Inform the patient about the importance of avoiding NSAID use. Collaboration: Inform all providers about the discontinuation of Nexium. Signed by: Telvin Mannat, Student Pharmacist, 04/06/18
The risk factors that Jessica presented with are a history that is positive for smoking, bronchitis and living in a large urban area with decreased air quality. The symptoms that suggest a pulmonary disorder include a productive cough with discolored sputum, elevated respiratory rate, use of the accessory respiratory muscles during quite breathing, exertional dyspnea, tachycardia and pedal edema. The discolored sputum is indicative of a respiratory infection. The changes in respiratory rate, use of respiratory muscles and exertional dyspnea indicate a pulmonary disorder since there is an increased amount of work required for normal breathing. Tachycardia may arise due to the lack of oxygenated blood available to the tissue stimulating an increase in heart rate. The pedal edema most probably results from decreased systemic blood flow.
Additionally, the LPN cannot push medications into a peripheral intravenous line if the patient “weighs less than 80 lbs, is prenatal, pediatric, or antepartum”, although given that the situation is on a general med-surg floor it is unlikely these patients would be under Sarah’s care at this time. (Rules and Regulations of Practical Nurses. 2015) Sarah can delegate the postoperative patients who need dressing changes and ambulating them to the LPN, but Sarah should assess the wounds for complications initially and serve as resource to the LPN if she has questions about the wounds. Additionally, she could help the nursing assistant with answering calls and serve as a reference for the nursing assistant to ask questions or help with tasks if Sarah is not available. With regards to supervision, the LPN would need continuous supervision given that the working relationship is new. (Cherry and Jacob, 2014) Sarah should be available and willing to answer any questions or address any concerns the LPN
Mrs. Jones has a history of COPD. She was already taking albuterol for her illness and it was ineffective when she took it that day. Mrs. Jones had been a smoker but had quit several years ago. According to Chojnowski (2003), smoking is a major causative factor in the development of COPD. Mrs. Jones's primary provider stated that she had a mixed type of COPD. The Global Initiative for Chronic Obstructive Lung Disease (GOLD) was established to address the growing problem of COPD. The GOLD standards identify three conditions that contribute to the structural changes found in COPD: Chronic bronchiolitis, emphysema, and chronic bronchitis. A mixed diagnosis means that the patient has a combination of these conditions (D., Chojnowski, 2003). Mrs. Jones chronically displayed the characteristic symptoms of COPD. "The characteristic symptoms are cough, sputum production, dyspnea on exertion, and decreased exercise tolerance." (D., Chojnowski, 2003, p. 27).
Based on the initial pain medicine evaluation report dated 06/22/15, the patient complains of constant neck pain which radiates down to the bilateral upper extremity, fingers and hands. Pain is accompanied by intermittent tingling and numbness in the bilateral upper extremities to the level of the fingers and muscle weakness. The neck pain is associated with occipital, temporal and frontal headaches and muscle spasms in the neck area. The patient describes the pain as aching, burning, pins and needles, sharp, and stabbing. The pain is aggravated by activity, flexion/extension, prolonged sitting, pulling, pushing, repetitive head motions and standing. She also reports severe difficulty in sleep.
Service. To prevent the development of chronic disease there is the treatment of acute or congenital cases is recommended. Antiparasitic drugs are not much effective in the
J.P., a 58 year old female, presents to the Emergency Room on March 18th. She has a past medical history of cervical cancer, atheroembolism of the left lower extremity, fistula of the vagina, peripheral vascular disease, neuropathy, glaucoma, GERD, depression, hypertension, chronic kidney disease, and sickle cell anemia. She complains of right lower extremity pain accompanied by fatigue, a decreased appetite, increased work of breathing, burning urination, and decreased urine output for three days. Upon admission, a complete physical assessment was performed along with a blood and metabolic panel. The assessment revealed many positive and negative findings.
The patient is a carpenter by trade with a high school education and lives with his wife who is disabled due to complications from T2DM. He and his wife live in an unsafe neighborhood where they share a one-bedroom apartment. His employment provides their only source of income and he experiences high levels of stress and anxiety as being sick jeopardizes his ability to make a living and care for his wife. He has poor exercise and dietary habits. His meals consist mainly of fast food for lunch and a large meal at the end of the work day, primarily meat and pasta.
*A history of frequent, acute, and severe metabolic complications (hypoglycemia, hyperglycemia, ketoacidosis) requiring medical attention
Bowers, L., Allan, T., Simpson, A., Nijman, H., & Warren, J. (2007). Adverse Incidents, Patient
Basically, there are two forms of treatments for ALD. In one form, treatments are used to prevent ALD from becoming fatal before the symptoms start. In the other form, the treatments are used for children who have already exhibited symptoms of ALD. The first form, know as pro-active treatments, include dietary therapy or administration of the cholesterol-lowering drug, lovastatin. The dietary therapy method encompasses the use of a low fat diet and consumption of Lorenzo’s Oil.
This chronic disease can be prevented, can be treated professionally at the very beginning of the process however, this disease cannot be cured. There are ...
Lisinopril- Nurse should monitor patient BP and pulse before and during therapy and check for signs of angioedema, if present discontinue therapy. Weight should be monitored and assessed for fluid overload. Patient should take medication at the same time every day and avoid food containing high levels of potassium or sodium due to the risk of hyperkalemia. Nurse should teach about the risk of orthostatic hypotension and dizziness, when changing positions or driving. Blood glucose levels should also be monitored for risk of hypoglycemia.
History of Present Illness: The patient is an 84-year-old Pacific Islander woman who presented to the clinic with complaints of a “bad” cough with phlegm which she notes to have started two weeks ago. She describes the cough as productive and the phlegm as rusty-colored. She states that the cough has been constant. Patient does not know what brought on the cough. She has been taking cough drops with no relief. She came to the clinic today because the cough has gotten worse. She reports that the cough is usually worse at night and sometimes prevents her from falling asleep. She has not tried any over the counter medication. She complains that her symptoms interfere with her daily activities.
As you consider treatment options that are available it’s important to keep in mind the following:
Patient profile: Heterosexual Muslim Woman who has been in the United Stated for three years. She came from Pakistan. She is 42 forty-two years old, from low socioeconomic standing, English language barrier, and is Muslim rituals and practices. She came to emergency department with her husband due to shortness of breathing, high fever, severe cough. She was dignosed with new onset of pneumonia and currently on antibiotic. she also has history of Vitamin D deficiencies and diabetes mellitus type II. She admitted to medical-surgical floor for observation...