M.J. is a 76-year-old woman who lives on the side of a very steep mountain. The home health 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 (250 mg twice a day), losartan (50 mg/day), levothyroxine sodium (Synthroid) (50 mcg/day), digoxin (0.125 mg/ day), furosemide (Lasix) (10 mg/day), aspirin (81 mg/day), simvastatin (20 mg/day), and warfarin (Coumadin)(4 mg/day, with 6 mg on Sundays). Allergies are to penicillin (hives) and to metoprolol (hypotension and dizziness). M. J. stopped smoking 5 years ago, but until then she smoked one-half pack a day.
Last laboratory test results (1 week ago) were: hemoglobin A1C (Hgb A1C) 8.3, international normalized ratio (INR) 1.7, sodium 129, potassium 5.8, chloride 102, CO 2 20, blood urea nitrogen (BUN) 45, creatinine 1.5, glucose 289, white blood cell (WBC) count 6.8, Hgb 10.1, 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 visual 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.
- J. has a heart murmur, described by the home health nurse as loudest over the right sternal border and more prominent in the systolic phase. Furthermore, the home health nurse tells you that she hears bruits on both sides of the neck, with the right being louder than the left. The blood pressure in the right arm is 135/72 mm 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 fi ngers have always been cooler than the right. Lungs are remarkable for wheezes. The patient has no fever. Oxygen saturations at room temperature are 90% to 92%, which has been her baseline.
Please answer the following question
- What concerns do you have regarding M. J. at this point?
- Do you need to see M. J. fairly soon, or can she come to see you at her regularly scheduled
appointment in 3 weeks?
- If you were to see M. J. in the next 24 hours, what additional tests would you perform?
- Based on the laboratory results given, what changes would you make in her medication profi le?
- Which arm will you use for blood pressure recordings in the future?
- What systolic blood pressure range would you order for M. J., as a general target?
- If M. J. has a repeat episode of right eye blindness, lasting 30 minutes this time, what would you do?