YEAR 2 PBL CASE 3 October 2015

STUDENT VERSION
Case Content: Year 2 PBL Case 3 (DAY 1)
Learning objectives for each PBL:
1) Orient self and others to the current PBL case and session and review goals of session.
2) Using a patients case as a framework for discussion, work as a group to identify gaps in knowledge
and transform these learning issues into questions that can be researched. All students must research
all issues chosen by the group for further study.
3) Identify and explore resources for self-directed learning.
4) Gather information independently from these sources and synthesize it in order to effectively discuss
new knowledge with your group.
5) Share your findings in a collaborative way that improves the collective knowledge of the group.
6) Give and receive feedback on the effectiveness of your contributions to the groups learning.
Learning goals specific to this case:
1) Evaluate a patient case to interpret findings, create a differential diagnosis, and evaluate treatment
options
2) Evaluate the issues of polypharmacy and management of chronic diseases in the elderly vs known
risks of many medications used to manage these conditions.
For expert help finding additional resources, call 852-8532 from 10 am to 2 pm on weekdays or email
kornref@louisville.edu
HPI:
Shelby Watkins is a 90-year-old woman who was brought to the emergency department by ambulance
because of chest pain and shortness of breath.
She woke up this morning earlier than usual because of pain in her left shoulder and jaw, and because she
felt like she was smothering. She was able to get out of bed and take her inhaler but felt too weak and
nauseated to make breakfast and her shortness of breath was still bad, so she woke up her roommate to call
the ambulance and bring her to the hospital. The EMS report states that she could not tolerate lying flat on
their stretcher due to shortness of breath. EMS also reports giving her sublingual nitroglycerin with reported
decrease in her pain, but that the pain did not completely go away. They also placed her on O2 via nasal
cannula at 2 liters per minute and noted oxygen saturations of 85% that increased to 88%, which then
prompted them to turn up the oxygen to 4 LPM. She says she has never had pain like this, and has not had
any cold or flu symptoms, fevers, or ill contacts. She has been taking her medicines according to the
schedule in pillboxes set out weekly by her home health aide.
PMHx:
She is in the ER of same hospital that has provided the majority of her care for the last 10 years. Review
of her last discharge summary reports a history of hypertension, renal-artery stenosis (for which a stent had
1

YEAR 2 PBL CASE 3 October 2015

STUDENT VERSION
been placed 2.5 years earlier), COPD, chronic renal insufficiency, gastroesophageal reflux disease,
hypercholesterolemia, and mild dementia involving poor memory and insight/problem-solving. She
previously had a hysterectomy and cataract surgery. This history is reviewed with Ms. Watkins, who
distractedly says Uh-huh. I cant really talk right now. Lord, help me!
Medications:
Lisinopril 20 mg daily, atorvastatin 20 mg daily, aspirin 81 mg, ranitidine 75 mg daily, calcitriol 0.5 mcg
daily, tiotropium inhaled BID, furosemide 40 mg PO BID, amlodipine 10 mg, alendronate 70 mg PO weekly.
She reports taking Motrin for aches and pains daily. You note also that she is given epoietin alfa
intermittently at renal specialist visits.
Social history:
She is a widow who lives with a widowed friend in a 2nd floor apartment with an elevator. She gets
assistance 3 times a week from elder care services, including groceries and cleaning, and a home health aide
comes in once a week to help with bathing and setting up her medications. She does not currently smoke,
but smoked 1 pack per day from the age of 15 until age 65. She does not drink alcohol.
Her children are grown one daughter lives in New York, the other in Arizona. She speaks to them regularly.
Family history:
Her brother died at age 75 with congestive heart failure, and also had a history of atrial fibrillation. Her
parents both died in a car crash in their 50s.
Physical Examination:
Triage vitals: T 99.7F, BP 199/108, HR 110, Sat 92% on 4L NC
Blood pressures equal in both arms
Gen: breathing quickly, appears uncomfortable, but able to speak in full sentences. Appears more
comfortable after 2 mg IV morphine and 2 additional doses of sublingual nitroglycerin.
HEENT: Some use of accessory muscles to breathe
Chest: Heart sounds tachycardic, regular, no appreciable murmurs. Neck is shown in different phases of
respiration:

YEAR 2 PBL CASE 3 October 2015

STUDENT VERSION
Lungs have bilateral crackles in the bases and there is some faint wheezing when she breathes out.
Abdominal: Soft, non-tender, non-distended. Bowel sounds present
Extremities: Warm to the touch, trace non-pitting edema in both feet. 2+ bilateral dorsalis pedis pulses.
Diagnostic studies:
WBC: 1200
AST: 225 (10Electrolyte panel:
Hgb: 13.1 (1340)
normal, including
16)
ALT: 20 (10-40) calcium,
Platelets:
phosphorus, and
386,000
magnesium
D-dimer: 1.02
Pro-BNP: 1100
Creatinine: 1.5
(normal <0.50
pg/mL
ng/mL (normal
mcg/ml FEU)
(normal <50
1.0 ng/mL),
pg/mL)
patient baseline
1.2 ng/mL
CK: 90 ng/mL
CK-MB: 10.2
cTroponin-I: 0.40
(ref range 40 to
ng/mL (ref
ng/mL
150)
range 0.0 to
(ref range 0.00 to
6.9)
0.09 ng/mL)
EKG and chest x-ray are pictured below.

YEAR 2 PBL CASE 3 October 2015

STUDENT VERSION

YEAR 2 PBL CASE 3 October 2015

STUDENT VERSION

YEAR 2 PBL CASE 3 October 2015

STUDENT VERSION
Hospital Course:
Cardiology evaluated the patient after the EKG was performed 10 minutes after arrival. She was started on IV
heparin, aspirin, statin, IV furosemide, and IV nitroglycerin in the ER within an hour of arrival. Her blood
pressure decreased to 150/80 and her chest pain was relieved once she was started on the IV nitroglycerin.
She urinated after being given the furosemide, and her breathing improved with a respiratory rate of
18/minute and O2 sats of 95% on 2L NC.
STOP HERE FOR DAY 1 OF THIS CASE. UPADTE GIVEN ON DAY 2.