Chana Kumar iHuman Fatigue 86 Year Old
Reason for encounter
Fatigue
History of present illness (HPI)
Chana Kumar is an 86-year old female with underlying osteoarthritis, constipation, hypertension, GERD, and hypercholesterolemia who presents today for evaluation of a 2-month history of generalized weakness and worsening fatigue. She also reports a 2-month history of mild dyspnea, palpitations and longstanding constipation. She acknowledges feeling tired both with rest and activities like walking around the block or going up the stairs. She feels relaxed when she wakes up in the morning but gets more tired as the day progresses. The SOB has progressively been worsening, relieved mildly with rest and worsens with activity. Yesterday about half an hour after her water aerobics class, she experienced a racing heart episode which she got relief with resting after the class. She informs that her constipation has been longstanding for several years and she still strains during bowel movements. She uses a colon cleanser which initially provided relief but does not help now. She denies chills, fevers, chest pain, blood in stools, swelling in face, lower, or upper extremities, or change in the shape of stools.
Case Findings
- Episode of racing heart (rate 120) 1 day prior to presentation
- Progressive fatigue and generalized weaknessx2 months
- Dyspnea on exertion, mild x2 months with acute exacerbation 1 day prior to presentation
- Tachycardia
- Conjunctival rim and palmer crease pallor
- Systolic ejection murmur (SEM)
- Chronic constipation
- Daily ASA use for secondary cardiac prevention
- History of hypertension on medication
- Coronary artery disease: S/P CABG(8 years ago)
- Osteoarthritis, takes NSAID
- GERD, takes proton pump inhibitors
Case Problem Statement
The patient is an 86-year old female with a history of HTN, CAD, S/P CABG 8 years ago who was at baseline 6 months ago but presents with an acute episode of tachycardia and dyspnea without chest pain, that started during routine exertion. She also has a 2 month history of progressive fatigue, generalized weakness, and mild dyspnea on exertion. She is normotensive, tachycardic (HR=110) with a flow murmur but negative for fluid overload. ROS only positive for constipation.
ORDER CHANA KUMAR iHUMAN FATIGUE 86 YEAR OLD
Management Plan
Diagnostic tests
- Diagnostic colonoscopy for colon cancer
- CT abdomen & pelvis
Medications:
- Patient to continue with current medications, no new prescriptions.
- Metoprolol 100 mg daily
- Nexium 40 mg daily
- Aspirin 81 mg Daily
- Lipitor 20mg daily
- OTC bowel cleansers
Suggested consults/referrals
- Nutrition consult for dietary assessment and further management.
- Gastroenterology consult for possible laparoscopic hemicolectomy (Ko et al., 2020).
Client education
- Educate patient about anemia including the etiology, signs and symptoms, management, complications, and prognosis.
- Educate the patient about the need for further diagnostic workup with laparoscopic hemicolectomy to evaluate for possible causes of the anemia such as colon cancer to alleviate current symptoms before seeking alternative intervention measures.
- Encourage patient to increase intake of fluids and fiber to relieve constipation.
- Encourage patient to increase intake of iron-rich foods including; red meat, beans, fruits, and dark leafy greens.
Follow-up
- Follow up with gastroenterology for laparoscopic hemicolectomy and close monitoring.
- Call 911 or visit the nearest ER if you develop difficulty breathing, worsening SOB, palpitations, loss of consciousness (LOC), or confusion (Ko et al., 2020).
Reference
Ko, C. W., Siddique, S. M., Patel, A., Harris, A., Sultan, S., Altayar, O., & Falck-Ytter, Y. (2020). AGA clinical practice guidelines on the gastrointestinal evaluation of iron deficiency anemia. Gastroenterology, 159(3), 1085-1094.
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