Chief Complaint-“I can’t catch my breath.

-Nina Orendorffis an 83-year-old woman who presented to the ED with generalized complaints,
feeling run down and unable to breathe. When evaluated by the ED nursing staff, her heart rate
was in the range of 110–120 beats per minute. The patient states that she has had progressively
worsening dyspnea on exertion over the last 2 weeks. Her shortness of breath has severely
limited her activities and has increased to persist even at rest.

PMH Family History Social History Medicine

- Type 2 DM ⋅5 years, - Father died at age - Retired -Minoxidil 10 mg po
diet controlled 85 of “old age”; schoolteacher who bid
- HTN x 40 years mother died at 88 lives at home alone;
after a hip fracture; reports enjoying a
one brother (age 80) cocktail while playing
alive with no cards with friends
significant history.

REVIEW OF SYSTEMS
Gen -Patient reports a recent weight gain Skin -Color pale; no unusual lesions noted
along with a general reduction in her state of HEENT -PERRLA, EOMI, fundi were not
health primarily related to an inability to get examined. She has complete denti-tion, and
around as she usually has in the past. her teeth are in fair repair.
CV -She has no complaints of any chest pain Neck - (+) JVD at 30°(6 cm). Carotid bruit is
but does report dyspnea on exertion, as well not appreciated. No lymphadenopathy or
as orthopnea and paroxysmal nocturnal thyromegaly
dyspnea. She has noted peripheral edema. Lungs/Thorax -Respirations are even. There
Resp -She reports shortness of breath and a are crackles in both lung fields posteri-orly
new cough that is not productive. She has not noted one-third of the way up the lung fields.
had any recent respiratory infections. There is no CVAT.
GI -She reports no recent changes in bowel Heart -Regular rhythm, no rubs, variation in
habits. intensity of S1 as expected; S3 appreciated at
GU -No complaints the apex in the lateral position; PMI displaced
MS -No complaints of MS pain or weakness, laterally and difficult to discern
just a general inability to exercise secondary Abd - Soft, NT/ND; (+) HJR; liver and spleen
to becoming “winded” slightly enlarged; no masses; hypoactive
Neuro -No abnormalities noted bowel sounds
Physical Examination Genit/Rect - Guaiac (–), genital examination
Gen -The patient is sitting up on the gurney in not performed
the ED in moderate distress. MS/Ext - 2+ pitting pedal edema bilaterally;
VS -BP 150/100, P 100–130 (regular), RR 28, radial and pedal pulses are of poor intensity
T 35°C; Wt 73 kg (usual weight 65 kg), Ht bilaterally; grip strength even
5'3‘’ Neuro - A & O ⋅3; CNs intact; DTR intact
MEDICATION RECORD
Drug Name Indication
Minoxidil  It is used for treatment of
severe hypertension
unresponsive to standard
therapy. It reduces elevated
systolic and diastolic blood
pressure.
Ipratropium  It is used for treatment for
bromide respiratory. It causes
bronchodilation by blocking
the acetylcholine action at the
parasympathetic site in
bronchial smooth muscle.
 \\\
Strengt Regimen Adverse Drug Reactions
h
 2.5mg  Daily Reflex tachycardia, fluid
retention, changes in ECG,
hypertrichosis, pericardial
effusion and tamponade,
pericarditis, exacerbation of
angina pectoris, headache,
nausea.
 20-  3-4  Dry mouth, constipation,
40mcg times tachycardia, palpitations,
daily arrhythmias, nausea and
vomiting, dyspepsia,
headaches, dizziness, ocular
complications
ASSESSMENT, PLAN AND FOLLOW-UP EVALUATION
Medical Drug-Therapy Problem
Condition
Type 2  
DM (controlle
d diet)
HTN  The patient has a medication
record of having
hypertension that causes her
a shortness of breath and
having a 110–120 beats per
minute heart rate. The
patient is suggested to
prescribe Minoxidil for her
hypertension but needed a
close monitoring as
combination with
ipratropium bromide may
increase blood pressure. The
patient heart failure is due to
her prolonged hypertension.
Dyspnea The patient experiencing
dyspnea or shortness of
breath
High blood pressure in your
pulmonary arteries causes
these arteries to become
narrow. 
Goal, Current Status Follow-up Plan
and Interventions
 The goal in this  A follow up is through
condition is to alleviate by continuously
her sugar level and to monitoring her blood
control her weight. As sugar level using a
the patient has type 2 glucometer and also to
DM, prescribed oral continue her visit in the
antidiabetic drug to hospital. Furthermore,
control her diabetes close monitoring in all
along with non- her medications is
pharmacologic action. needed to ensure that
no possible drug
interaction may put her
life in danger.
 The patient has a  For this medication is
Hypertension that through by continuously
causes her heart rate monitoring her blood
increase 110–120 pressure level and also
beats per minute, to continue her visit in
where patient the hospital. Also,
experiencing monitoring in all her
tachycardia. The medications is needed to
medication prescribe ensure that no possible
for the patient is drug interaction may put
Minoxidil to reduce her her life in danger.
blood pressure.
The goal in this  A follow up is through
condition is to relieve by continuously
the patient for having monitoring and her visit
shortness of breath. As in the hospital regularly.
the patient has Furthermore, close
hypertension that monitoring in all her
causes her dyspnea, a medications is needed to
prescribed ipratropium ensure that no possible
bromide is needed drug interaction may put
along with non- her life in danger.
pharmacologic action.