CASE STUDY 2

Family History

Past Medical History

Past Surgical History

Social History

Measurements

Height: 65 in

weight: 159 Ib, 72.27 kg

Hysterectomy

Father: Heart Disease

Mother: Heart Disease

Alcohol: NO

Tobacco: Cigarettes

Anxiety

Emphysema/ COPD

Hyperlipidemia

CASE STUDY 2

Medications

Patient is 75-year-old female with COPD returns the hospital with shortness of breath. Patient still have COPD exacerbation and had parainfluenza last month. She is able to wean her oxygen back down to 2 L but did require skilled level stay. She has been home approximately 2-3 weeks where she has had some mild debility However, 3 days ago she tripped over her oxygen cord and fell striking her table. She had immediate pain to the left side but was able to get back up. The following day she was sore but still able to move around in the house. She did have shortness of breath and slowly increase her oxygen.

A day before she increased her oxygen to 4 and continues to have pain and shortness of breath. At this point she reports the emergency department for further evaluation . In the emergency department she was Satting at 90 % on 4 L nasal cannula. X-ray revealed a left pleural effusion. Subsequent shows rib fractures and effusion to be larger than it appeared on x-ray. As well, there is bilateral PE. With that information she is being admitted for further care. She denies any leg swelling and does have chest pain on the left which she attributed to the fall. She completed prednisone at home and has been using Details: her inhalers as instructed. There is been no nosebleeds hematemesis melena hematochezia.

Assessment/ Plan Diagnoses

ABDULRAHMAN TAI

Pulmonary embolus: Patient's found to have bilateral pulmonary embolus on CT today. She did have an acute illness last month and went through skilled level care. She also fall 3 days ago H but has still been mobile albeit not as active as usual. Now she is developed PE. She does have a large pleural effusion and is going for an urgent thoracentesis. We will start heparin after thoracentesis as long as it is not overtly bloody. She is being admitted special care with these concerns. Will alert her pulmonologist of these findings for assistance as well. Will ultrasound lower extremities for DVT.

Advanced COPD: Continue with her bronchodilators and oxygen. Reevaluate oxygen needs after thoracentesis.

Hyperglycemia: Patient's blood sugar did elevate the last month while she was on steroids. Will check A1c and have NovoLog sliding scale available.

Hypertension: Losartan and amlodipine adjusted during her last admission and will continue now. Follow with telemetry.

Pleural effusion: Patient with a considerable left pleural effusion. For thoracentesis now and will send indices.

Rib fractures: Pain control to be administered. Fractures appear minimally displaced

XR Chest

Patient Data

References

Do you have any question?

Name 2 medication and their category?

Lab results

Heart: Normal

Lung: Patchy left basilar airspace opacity blinting of left costophrenic recess. No pneumothorax

https://www.lung.org/lung-health-and-diseases/lung-disease-lookup/emphysema/

https://www.webmd.com/lung/what-is-a-pulmonary-embolism

What kind of COPD the patient have

Thank you