21 year old female patient admitted via emergency to the sixth floor, suffering from shortness of breath for one day ,with productive cough ,frank hemoptysis, orthopnea ,exert ional dyspnia ,legs sweeling,high blood pressure.

She is a previous diagnosed case of :

1-    takaysu disease

2-    previous re current attack of pulmonary edema

3-    hyper tension

she was diagnosed as case of acute pulmonary edema

 here medication during hospitalization is :

-antibiotic cefuroxime : for treatment of suspected infection         

-aspirin: anti inflammatory for takayasu disease

-ticlopidin:for risk of thrombus development because she has renal artery stenosis secondary to takayasu disease       

-famotidin:for treatment of GIT symptoms caused by stress due to hospitalization, and because here medication has GIT side effect especially aspirin and prednison

-furosemi:dediuretic for treatment of pulmonary edema

-prednison: anti inflammatory for takayasu

-amlodipin: Ca channel blocker for hypertension.

Carvidolol: b-blocker for hypertension

-KCl : treatment of hypokalemia developed during hospitalization        

  she responds well to therapeutic plane .. respiratory symptoms decreased in severity , and here hypertension are becoming more stable

Name of patient  : a.o.k

Address               : Amman    

Date of birth       :1/1/1962    

Social status      : single

Height                   : 160 cm   

Weight                : 56 kg        

Admission date   : 17/7/2000

Discharge date    :

Chief compliant : shortness of breath for one day ,with         productive cough ,frank hemoptysis, orthopnea ,exert ional dyspnia ,legs sweeling,high blood pressure.

patient admitted to hospital suffering from chest pain , shortness of breath ,cough with some blood in sputum, chills and riders ,and increase in lower limb edema and general fatigue and weakness.

She is a previous diagnosed case of

1-takaysu diseases

2-previous re current attack of pulmonary edema

3-hyper tension

Blood pressure : 150/90

Heart rate         :110/min       

Temperature       :38.0

Left arm            : no pulse

 -Head and neck : normal finding    

-Chest: coarse crepetaion all over chest up to apex

-Heart: no odd sounds, increase in intensity of s1 and s2

-Abdomine:soft with no masses

-Limbs:bilateral pitty edema

measured by doctor:

 1-    monitor for cardiac function because B-blocker and Ca channel blocker therapy may predispose to cardiac depression.

2-    Do not incraese dose of aspirin if patient continue on furosemide therapy bec high dose of aspirin may predispose to salicylate toxicity (patient now under low dose aspirin 325 mg once dialy)

3-    Upon discharge of patient if methotrexate therapy is initiated for long term treatment of takayasu disease take into considration aspirin dose because it may increase toxicity of methotrexate so it is better to hold aspirin but if it is a vital therapy decrease dose of methotrexate and aspirin.

4-    Ticlopidin decrease effect of corticoids so increase dose of it .

5-    Also ticlopidin increase toxicity of aspirin so it is better to hold aspirin or decrease dose.

- patient has developed hypokalemia during hospitalization in day 24/6/2000 and so she was received KCl supplement and respond good to treatment ,here K level is rising .

-when she admitted she has a normal glucose level but she developed hyperglycemia,this happened due to prdnison high doses ,she is not diabetic patient so treat by diet control and no hypoglycemic therapy is required and here prednison dose will be tapered to decrease side effect .

-patient had dyspnia upon admission so she was put on oxygen therapy here oxygen level improved significantly rise from 31 t0 60 while normal is 83-108 ,also saturation

improved significantly from 56% raised to 91%

-she had increase of cratinine because of furosemide therapy with aspirin but it is under control and decreased again.

-in 24-7-2000 we increase dose of amlodipin because here hypertension still not controlled

- she developed side effect of moon face due to prednison therapy

 -here dose of prednison will be tapered to decrease side effect and tapering will start during hospitalization tell she reach 20 mg / day upon discharge.

Problem : hypertension

S : hedach , general weakness and feeling unwell

O: high blood pressure upon admission 150/90     

     Unstable blood pressure during hospitalization(see vital sighn table pagr(  ))

 A :patient has uncontrolled hypertension which followes type 2 and 3 hypertension

  P:

-Drug therapy plan

Monitor:

Wight , blood pressure,electrolyte,heart function,

-educational plan 

low salt diet

fluied restriction

self control of blood pressure           

about drugs: Regarding furosemide inform patient to take with food  , rise slowly from lying to setting to avoid light headness and fainting side effect,take last dose early in evining to prevent nocturia .

regarding amlodipin iform patient not to discontinue abruptly (inform doctor),report any dizzens or shortness of brath or edema to doctor.

 -future plan:

come back to clinc after four weeks to monitor blood pressure and to monitr complication.

 Problem: pulmonary edema

S :chest pain ,shortness of breath,orthopnia,excertionaldysbnea,frank hemoptesis,chestpain, , cough with blood in sputum.

O: crepitation in chest upon examination Tachycardia, Peripheral oedema, variable blood pressure,chest x-ray finding ,pO2 30 mmHg ,saturation

A : patient diagnosed as pulmonary edema case.

P :

Thaeraputic plan:

Monitor:wight,blood pressure, electrolytes,signs and symptoms of anaphylaxis , heart function , renal and hepatic function,monitor blood gases for evaluation of oxygen therapy.

Educational plan:

-         Education and counselling measures for patient and family, general, diet and medication related.

-         Regarding furosemide inform patient to take with food  , rise slowly from lying to setting to avoid light headness and fainting side effect,take last dose early in evining to prevent nocturia .

-         Regarding cefuroxime inform patient a bout importance of duration of therapy ,he should take all the doses and since it is IV no problem but if shift to oral anti biotic complet duration of tharapy

Future plan:

Come back to clinic during 4-weeks to follow up and monitor for any complication or recurrence .

Problem: takayasu disease

 S: fever,fatigue, wight loss , non specific aches,pain in limbs .

O:high blood pressurs,pulsless in left arm,clinical diagnosis previously as takayasu disease

A:patient is a takayasu disease patient (see more about disease in page (  )

P:

Thaeraputic plan:

Monitor :monitor ringing in ear , bleeding disorders , electrolyte, blood glucose ,blood pressure.

Educational plane :

-Tell patient about disease and drug therapy

-regarding aspirin inform patient to take it with food and to watch for GIT bleeding , and to inform patient if any ringing in ear happened ,and to avoid other aspirin cotaining medications.

-Regarding prednison inform patient to take with food to decrease GIT side effect,avoide abrupt withdraw , inform doctor about any infection.

Future plane :

Patient come back to clinic for monitoring drug therapy and assessing any complication.

Symptoms

• Acute dyspnoea
• Cough, frothy sputum

Signs

• Tachycardia
• BP variable
• Lung crepitations
• Other congestive signs
• JVP elevated
• Peripheral oedema
• Cardiac enlargement - apex beat displaced
• Gallop rhythm - apical third heart sound, S3

Past history - may indicate

• previous subacute or chronic heart failure
• Dyspnoea on exertion, orthopnoea, nocturnal dyspnoea
• Peripheral oedema
• Decreased exercise tolerance
• causative or precipitating factors
• Angina or myocardial infarction
• Hypertension
• Valvular heart disease
• Heavy alcohol consumption
• precipitating factors
• Respiratory infection
• Arrhythmias
• Anaemia
• Hyperthyroidism
• Volume overload (transfusion)
• relevant medication
• Cardiac depressant drugs
• Non steroidal antiinflammatory drugs

• CXR (heart size, pulmonary oedema vs infection, consolidation)
• ECG (brady or tachyarrhythmia, AF, ischaemia, previous or silent MI, LV hypertrophy)
• Arterial blood gas (hypoxia, metabolic acidosis)
• Blood biochemistry (Cr, Na⁺, Ksps+)
• Hb, WBC and differential
• Thyroid function tests ("unexplained" AF and HF in elderly)
• Echocardiography after acute treatment and stabilisation (LV size, function, wall thickness, valvular and other abnormalities)

• Lack of compliance with previo

Initial measures

• Sit patient upright with legs down ('armchair' position)
• Oxygen at 4-6 L/min (maintain SaO₂ > 90%)
• Morphine 2.5 mg iv over 2-3 minutes, repeated once if necessary (monitor respiration)
• Frusemide 40-80 mg iv repeated as necessary
• Glyceryl trinitrate sublingual tab or spray, repeated dosage according to blood pressure or alternatively by iv infusion (local protocols)

Subsequent treatment

After review, generally in CCU, ICU

• Digoxin for ventricular rate control in atrial fibrillation and flutter, loading dose 1.0-1.5 mg iv or oral in divided doses over first 24 hr, then 0.25 mg daily (less in the elderly and with renal impairment)
• Dobutamine iv infusion up to 10-15 mcg/kg/min (inodilator effect)
• Dopamine iv infusion up to 5-10 mcg/kg/min if persistent hypotension (inoconstrictor effect)
• Continuous positive airway pressure

Review clinical presentation and investigations including echocardiogram to determine remediable causes or precipitants and to guide management decisions:

• LV global ischaemia (pulmonary oedema resolving, ECG ST-T changes, relatively normal LV size and function on echo).
• Occult valvular disease - AS, MS
• Uncontrolled hypertension
• Hyperthyroidism in the elderly
• Previous medications

Plan further investigations / referral / intervention for the above if required.

Plan maintenance treatment

• Diuretic/ACE inhibitor combination for HF with LV systolic dysfunction.
• Digoxin for AF and an optional addition for patients in SR.
• Aspirin for all patients with coronary disease.
• Selective anticoagulation for high risk patients with AF and those with marked LV impairment

Other important aspects of care

• Education and counselling measures for patient and family, general, diet and medication related.
• Plan integrated follow up with primary care.