Discussion w11 650

Q-1 76-year-old male patient, German descent, physically active, with a known medical history of hypertension, asthma, long term smoker present with complaints of shortness of breath (SOB) started 6 months ago, worsens during strenuous exercise, especially walking, and needing more time to complete his 1-mile distance walk and have to stop walks in between due to SOB and feels heart fluttering, wheezing at times and use of inhaler makes the heart flutter more frequent and worse with occasional sweating at night. Chronic obstructive pulmonary disease (COPD):-On examination by inspection, his AP diameter is 1:2 which is normal without barrel chest, on auscultation coarse crackles (popping) heard at the beginning of inspiration are commonly seen in COPD patients which is positive in this patient. The pulmonary function test (PFT) with low FVC 3.15 and predicted is 4.08 which 77% and the normal is 81-83%, positive FEV1 is 2.24 and the predicted is 3.17 which is only 71% and the normal is 81-83%, VC-is 3.14, predicted is 4.08 low 77% and TLC- is 4.85, predicted is 6.42 which is also 76%. So positive PFT is diagnostic of COPD. Chest x-ray reveals mild cardiac enlargement which is positive in COPD. Echo findings with scarring of right mid and lower lung base with mild cardiomyopathy are consistent with COPD findings. Physical activity is consistently associated with clinical and functional determinants of COPD including dyspnea and exercise capacity which has a negative impact patient’s physical activity and perceived symptom burden (Miravitlles, & Ribera, 2017). Atrial flutter: Patients with COPD are more at risk of developing cardiac arrhythmias such as atrial fibrillation and atrial flutter due to pulmonary hypertension and cardiomegaly. This patient presents with a symptom of SOB with a feeling of fluttering at times and more frequent with the use of inhalers which is a beta-agonist that usually makes increased heart rate and tachycardia. EKG shows sinus arrhythmia and exercise makes the demand of the heart higher and the heart is unable to compensate for the demand, which may produce atrial flutter and tachyarrhythmias. Negative thyroid function test TSH (1.9), T4-(7.6) ruled out the metabolic or endocrinal cause. COPD is independently associated with atrial fibrillation, diastolic dysfunction, changes in the atrial size by altered respiratory physiology, increased arrhythmogenicity foci commonly located in the right atrium and cardioselective beta-blockers can be safely used in COPD patients (Goudis, 2017). coronary artery disease with ST elevation in Lead V2, V3, V4- septal wall MI: Patient’s present with shortness of breath during exercise with positive risk factors such as hypertension (BP-155/95), smoking (long term), hypercholesteremia, positive family history of father died from a heart attack at age 62 older age contributes coronary artery disease and family history of hypertension in mother and two sisters make me investigate more into this by coronary angiography. I could see some ST elevation in V2, V3, V4 leads denotes septal wall ischemia and Echo findings with mild cardiomyopathy. According to Goedemans, Bax, & Delgado, (2020), Patients with COPD carry an increased risk of acute myocardial infarction with an increased risk of adverse events at follow up. Hypercholesteremia: This patient present’s cholesterol level of 220 with an LDL of 122 HDL of 44 is all moderately high. Patient with a positive history of long-term smoking, hypertension with a positive family history of heart attack and not on any cholesterol-lowering agents and treatments needs to be initiated to reduce cardiovascular mortality. According to Volpe, et al

(2017), clinical management of hypercholesteremia has a fundamental role in preventive strategies of primary and secondary prevention at each stage of cardiovascular risk. I think this is a perfect scenario for pulmonary and cardiac problems in the elderly with a known history of hypertension, smoking and present with symptoms of shortness of breath with the fluttering of heartbeat for me to learn and I also see the same situation in my work too, dealing with COPD and associated comorbidities and complications which end up in admitting to ICCU. Reference. Miravitlles, M., & Ribera, A. (2017). Understanding the impact of symptoms on the burden of COPD. Respiratory research, 18(1), 67. Retrieved from https://respiratory-research.biomedcentral.com/articles/10.1186/s12931-017-0548-3?optIn=false Goudis, C. A. (2017). Chronic obstructive pulmonary disease and atrial fibrillation: an unknown relationship. Journal of cardiology, 69(5), 699-705. Retrieved from https://www.sciencedirect.com/science/article/pii/S0914508717300163 Goedemans, L., Bax, J. J., & Delgado, V. (2020). COPD and acute myocardial infarction. European respiratory review, 29(156). Retrieved from https://err.ersjournals.com/content/29/156/190139.short Volpe, M., Volpe, R., Gallo, G., Presta, V., Tocci, G., Folco, E., ... & Trimarco, B. (2017). 2017 position paper of the Italian society for cardiovascular prevention (SIPREC) for an updated clinical management of hypercholesterolemia and cardiovascular risk: Executive document. High blood pressure & cardiovascular prevention, 24(3), 313-329. Retrieved from https://link.springer.com/article/10.1007/s40292-017-0211-6 Q-2 After reviewing the case and seeing the patient, his chief complaint of "I get short of breath during my walks" help me focus on the cardiopulmonary circuit as the etiology of this patient's complaint. After discussing with the patient I found that the patient was not taking his inhalers as previously prescribed because they gave him heart palpitations, and he was continuing to smoke. Another important item the patient mentioned was that he was feeling like he was wheezing during exercise. Moving on to the evaluation portion, IU wanted to check the most common tests related to cardiopulmonary function. So for this reason I wanted to order an EKG, ECHO, BNP, CXRAY, and a PFT (Agarwal, Raja, & Brown, 2020); (Malik, Brito, & Chhabra, 2020). For the EKG it showed sinus rhythm, ECHO showed left ventricle hypertrophy with an ef of 55%, and the BNP was elevated at 600, all of which are indicators of congestive heart failure (Agarwal, Raja, & Brown, 2020). With these results, the patient would have been classified by the NYHAC scale as a Class III as this has begun to impact his daily life (Agarwal, Raja, &

Brown, 2020). The treatment I wanted to initiate on this patient included an ACEi or an ARB depending on the patient's financial situation, as well as begin Lasix 40 mg PO daily in order to help relieve some intravascular volume and stress on the heart (Agarwal, Raja, & Brown, 2020). I also wanted to refer him to a cardiologist for further recommendations and management (Agarwal, Raja, & Brown, 2020). For the CXRAY and PFT, the CXRAY was clear with mild atelectasis, but the PFT revealed FEV1-3 at 70-75% which is close to being able to confirm a diagnosis of COPD at least at stage II but is most likely being exacerbated by the onset of the patient's worsening CHF (Malik, Brito, & Chhabra, 2020). I would recommend a LABA such as Pulmicort for the patient's report of wheezing and PFT results but would emphasize a referral to a pulmonologist for recommendations and treatment (Malik, Brito, & Chhabra, 2020). It could be that the patient improves greatly with the treatment of his CHF and he won't need inhalers (Malik, Brito, & Chhabra, 2020). Now, the other issue is that the patient has a history of being non-compliant with a legitimate complaint but without reporting to the physician. I would have to have an in-depth conversation with the patient in order to convey the importance of not stopping these medications and the ease of which he could call and report disliking the medication and the possibility of getting him on a different regimen that would work for him. Of course, this is all depending on the patient agreeing to quit smoking and that will be a lengthy conversation in and of its own. References: Agarwal, A.K., Raja, A., Brown, B.D. (2020). Chronic Obstructive Pulmonary Disease. StatPearls Treasure Island StatPearls Publishing. Retrieved from: https://www.ncbi.nlm.nih.gov/books/NBK559281/ Malik, A., Brito, D., Chhabra, L. (2020). Congestive Heart Failure. StatPearls Treasure Island StatPearls Publishing. Retrieved from: ​https://www.ncbi.nlm.nih.gov/books/NBK430873/ Q-3 Identification of older adults at risk for mobility limitation, visual, and hearing difficulties can be accomplished through routine screening in the ambulatory setting. Addressing functional deficits and environmental barriers with exercise and mobility devices can lead to improved function, safety, and quality of life for patients with physical limitations. Mobility, including the ability to walk and/or climb stairs, is an important predictor of quality-of-life among older adults and a measure of successful aging. Mobility limitations put older adults at risk for falls, reduced access to medical services, poor psychological health, declining functional

abilities and negative health outcomes. The onset of chronic conditions, such as arthritis and chronic lung problems, are the most common causes of mobility-related disabilities in older adults. Mobility problems, including changes in gait, are early indicators of health decline and subsequent disability. The onset of chronic conditions, such as arthritis and chronic lung problems, are the most common causes of mobility-related disabilities in older adults. Mobility interventions including falls prevention approaches generally focus on balance and muscle strengthening exercises as most effective in addressing the primary cause of falls and mobility issues (Brown & Flood, 2018). With aging, the gradual deterioration of sensory modalities, including vision, can interfere with one's daily activities. The most common visual change with increasing age is a gradual loss of the ability to focus on near objects or presbyopia. Geriatric patients are also prone to further visual impairments such as glaucoma. These visual impairments are related to a higher incidence of falls in the geriatric population, especially at night. In the majority of the geriatric population, eyeglasses are sufficient to correct the visual impairments described above. Others may need to be medically or surgically managed. Large-print material and devices (eg, telephone with large numbers) can facilitate the patient's daily activities. Similarly, talking clocks and watches are also useful. Handheld or standing magnifying glasses are inexpensive and effective for reading small print, such as that on price tags or financial statements (Keller & Flood, 2018). The likelihood that a patient over the age of 65 years has significant hearing loss is high. Furthermore, the prevalence of hearing loss increases in people older than 75 years. Not all hearing impairments are reversible. Poor vision, a high level of comorbidity, and depression are related to hearing loss in the elderly. Hearing loss has a major contribution to communication and quality-of-life issues. Examples of impairments that are potentially reversible involve cerumen, cholesteatomas, or acoustic neuromas. These conditions should be recognized and the patient referred to an appropriate subspecialist, such as an ear, nose, and throat (ENT) specialist or a neurosurgeon. Screening for hearing loss is a valuable tool for early intervention. It is useful to ask patients and their family member about any changes in the patient’s hearing (Keller & Flood, 2018). Hearing acuity can be tested, when a hearing impairment is established, a formal consultation with an audiologist and the involvement of a speech and language pathologist are pertinent. Brown, C. J., & Flood, K. L. (2018). Mobility limitation in the older patient: a clinical review. JAMA, 310(11), 1168–1177. https://doi.org/10.1001/jama.2013.276566 Keller, B. & Morton, J.L, (2019). The effects of visual and hearing impairments on functional status. Journal of American Gerontology Society, 7(11):1319-25.