Question

M.J. is a 76-year-old woman who lives on the side of a very steep mountain. The home helath nurse has visited her once a week for the last year. She has running water, electricity, and a coal stove with back-up oil heat for very cold winter nights. She uses the telephone for communication. She has diabetes mellitus, hypertension, hypothyroidism, and is in atrial fibrillation. She has never been in the hospital before. Her current medications include metformin 250mg twice a day, losartan 50 mg daily, levothyroxine 50 mcg daily, digoxin 0.125mg daily, lasix 10mg daily, aspirin 81 mg daily, simvastatin 20mg daily, warfarin 4 mg day with 6 mg on sundays. Allergies are to penicillin and metoprolol. M.J. stopped smoking 5 years ago, but smoked one-half pack a day. Last laboratory test results 1 week ago were: hemoglovin A1c 8.3, INR 1.7, sodium 129, potassium 5.8, chloride 102, CO2 20, BUN 45, creatine 1.5, glucose 289, WBC 6.8, Hgb 10.2, hematocrit 30.2, platelets 215, 000. The home health nurse calls you from the patient's house, where she notes that the patient had a 5 minute spell of viusal loss in her right eye. It has not recurred. During this period, M.J. noted that her left hand and left leg felt funny, and her left foot and leg were so weak that she could not walk. M.J. has a heart murmur, descrived by the home health nurse as loudest over the right sternal boarder and more prominent in the systolic phase. Furthermore, the home health nurse tells you that she hears bruits on both sides of her nect, with the right being louder than the left. The blood pressure in the right arm is 135/72mm Hg and 110/66 mm Hg in the left arm. Heart rate is irregular at 75 to 90 beats per minute. The left hand and fingers have always been cooler than the right. Lungs are remarkable for wheezes. The patient has not fever. O2 Sat at room temperature are 90% to 92%, which has been her baseline. 1. What concerns do you have regarding M.J. at this point? Concerns that I have for this patient would be she lost vision in her right eye for 5 minutes. During this spell she also experienced her left hand and left leg feeling funny and her left foot and leg were so weak that she should not ambulate. 2. Do you need to see M.J. fairly soon, or can she come to see you at her regularly scheduled appointment in three weeks? 3. If you were to see M.J. in the next 24 hours, what additional tests would you perform? 4. Based on the laboratory results given, what changes would you make in her mediation profile? 5. What arm will you use for blood pressure recordings in the future? 6. What systolic blood pressure range would you order for M.J., as a general target? 7. If M.J. has a repeat episode of right eye blindness, lasting 30 minutes this time, what would you do?

Answer 1

Q. No. 1. Answer :

We need to concern M. J regarding, " carotid artery stenosis ", because in this only we will listen the Bruits, it is not related to any diseases, due some stenosis of carotid artery there is no proper blood circulation and threw is a loss of function of lower limb mainly left side.

So we can abserve for that, and we need to concern that, it may leads to any time heart attack may come.

Q. No. 2. Answer :

Yes, we need to see M. J fairly soon, because she can not able to come on regular schedule, as she is suffering from weakness on left foot and leg and cool ness on left hand fingers than right hand, it is due to decreased blood circulation, it may leads to any time there is a chance to heart attack.

And we will see sudden loss of vision, imbalance in walking, lack of coordination .

So need to see M. J soon.

Q. No. 3. Answer :

Additional tests should be performs like

* carotid Doppler and ultrasound for the neck.

* CT Angiogram of the neck.

* magnetic resonance angiography, should be done.

Q. No. 5. Answer :

The arm should which shows higher blood pressure in that arm we will check the blood pressure.

Because in the left side carotid artery is having stenosis because the patient is showing symptoms like this, low blood pressure on left side arm, and weakness on left foot and cool fingers on left, it indicates left side carotid artery is affected .

So in future we need to consider right side arm blood pressure to get correct values.