Presenting Case Esther Explained for Students (Easy Guide)
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Original Question
Presenting Case: Esther Brown is a 68-year-old Caucasian female who presents to the Emergency Room with the complaint of shortness of breath and chest discomfort a few days after a large family BBQ 2 weeks ago. She reports that she can’t sleep well lying in bed, wakes up short of breath, and has needed to sleep in the recliner over the past week. She also complains because she had to make her belt bigger and her legs look “fat and puffy” despite having a decreased appetite over the last 1 1/2 weeks and not eating much. She has been more fatigued lately so has not been getting her usual walk-in. PMH: Myocardial Infarction 5 years ago with a 2-vessel coronary artery bypass graft Hyperlipidemia- diagnosed 9 years ago BMI 40 Osteoarthritis Current Medications: Atorvastatin 80 mg qd – (Lipitor). HMG-CoA reductase inhibitor. Antihyperlipidemic. Lisinopril 10mg qd – ACE inhibitor. Antihypertensive. (Initial dose 10 mg daily, maintenance 20-40 mg per day, max 80 mg per day). She is taking a pretty low dose of Lisinopril, and the celecoxib may decrease the antihypertensive effects of it. Celecoxib 200 mg qd – (Celebrex). NSAID. Analgesic, anti-inflammatory, antirheumatic. (Adults 100-200 mg/day). Relieves signs and symptoms of rheumatoid arthritis. Contraindications: decreases antihypertensive effects of ACE inhibitors, angio II receptor antagonists, and beta blockers. Adverse reactions: cerebral hemorrhage, CVA, bradycardia, aortic valve incompetence, congestive heart failure, DVT, MI, unstable angina, ventricular fib and ventricular hypertrophy, Aspirin 81 mg qd – Salicylate. NSAID (anti-platelet, antipyretic, nonopioid analgesic). Interactions: ACE inhibitors-beta blockers, decreases the antihypertensive effect. Adverse reactions: CNS depression, GI bleed, Hepatotoxicity, leukopenia, prolonged bleeding time, thrombocytopenia, angioedema, Reye’s syndrome. Allergies: Atenolol -hives, Cats- itchy nose Exam findings: BP 158/92, P 110 regular, R 24, T 98.4F, O2 sat 91% on RA, Pain 1 out of 10 Restless, sitting upright in bed, appears anxious Breath sounds – breathing labored, coarse crackles on inspiration and expiration scattered throughout both lung fields anterior/posterior Forehead diaphoretic, 3+ pitting edema bilateral lower extremities in feet, ankles, 3+ up to knees bilaterally, S3 gallop most prominent over apex, no jugular venous distention (JVD) noted sitting up at 45 degrees Abdomen, pale, symmetric, soft, and non-tender, bowel sounds present in all four quadrants- normoactive An echocardiogram done 6 months ago showed an ejection fraction of 25% Section 6: Create 3 Subjective Questions to Effectively Assist in the Plan of Care for Chest Pain/SOB Are you experiencing any pain with your shortness of breath now? What is your diet like? What decreases your pain and shortness of breath? Section 7: Identify 3 Education Topics/Lifestyle Suggestions with Rationale to Promote Health for the Client DASH Diet could be implemented to help her safely lower her BMI. Additionally, the lower sodium could help reduce the pitting edema she is experiencing. Medication change? Consult a physician about celecoxib. Should this medication be continued? It seems to interact with lisinopril. Consider a diuretic for edema. WHAT ELESE??
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