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Shelby Watkins: The Case: Day 1

Day 1


Shelby Watkins is a 90-year-old woman who was brought to the emergency department by ambulance because of chest pain and shortness of breath.

She woke up this morning earlier than usual because of pain in her left shoulder and jaw, and because she felt like she was smothering. She was able to get out of bed and take her inhaler but felt too weak and nauseated to make breakfast and her shortness of breath was still bad, so she woke up her roommate to call the ambulance and bring her to the hospital. The EMS report states that she could not tolerate lying flat on their stretcher due to shortness of breath. EMS also reports giving her sublingual nitroglycerin with reported decrease in her pain, but that the pain did not completely go away. They also placed her on O2 via nasal cannula at 2 liters per minute and noted oxygen saturations of 85% that increased to 88%, which then prompted them to turn up the oxygen to 4 LPM. She says she has never had pain like this, and has not had any cold or flu symptoms, fevers, or ill contacts. She has been taking her medicines according to the schedule in pillboxes set out weekly by her home health aide.


She is in the ER of same hospital that has provided the majority of her care for the last 10 years. Review of her last discharge summary reports a history of hypertension, renal-artery stenosis (for which a stent had been placed 2.5 years earlier), COPD, chronic renal insufficiency, gastroesophageal reflux disease, hypercholesterolemia, and mild dementia involving poor memory and insight/problem-solving. She previously had a hysterectomy and cataract surgery. This history is reviewed with Ms. Watkins, who distractedly says “Uh-huh. I can’t really talk right now. Lord, help me!”


Lisinopril 20 mg daily, atorvastatin 20 mg daily, aspirin 81 mg, ranitidine 75 mg daily, calcitriol 0.5 mcg daily, tiotropium inhaled BID, furosemide 40 mg PO BID, amlodipine 10 mg, alendronate 70 mg PO weekly. She reports taking Motrin for “aches and pains” daily. You note also that she is given epoietin alfa intermittently at renal specialist visits.

Social history:

She is a widow who lives with a widowed friend in a 2nd floor apartment with an elevator. She gets assistance 3 times a week from elder care services, including groceries and cleaning, and a home health aide comes in once a week to help with bathing and setting up her medications. She does not currently smoke, but smoked 1 pack per day from the age of 15 until age 65. She does not drink alcohol.

Her children are grown – one daughter lives in New York, the other in Arizona. She speaks to them regularly.

Family history:

Her brother died at age 75 with congestive heart failure, and also had a history of atrial fibrillation. Her parents both died in a car crash in their 50s.

Physical Examination:

  • Triage vitals: T 99.7F, BP 199/108, HR 110, Sat 92% on 4L NC
  • Blood pressures equal in both arms
  • Gen: breathing quickly, appears uncomfortable, but able to speak in full sentences. Appears more comfortable after 2 mg IV morphine and 2 additional doses of sublingual nitroglycerin.
  • HEENT: Some use of accessory muscles to breathe
  • Chest: Heart sounds tachycardic, regular, no appreciable murmurs. Neck is shown in different phases of respiration. See Figure 1.
  • Lungs have bilateral crackles in the bases and there is some faint wheezing when she breathes out.
  • Abdominal: Soft, non-tender, non-distended. Bowel sounds present
  • Extremities: Warm to the touch, trace non-pitting edema in both feet. 2+ bilateral dorsalis pedis pulses.

Diagnostic studies:

WBC: 1200

Hgb: 13.1 (13-16)

Platelets: 386,000

AST: 225 (10-40)

ALT: 20 (10-40)

Electrolyte panel: normal, including calcium, phosphorus, and magnesium

D-dimer: 1.02

(normal <0.50 mcg/ml FEU)

Pro-BNP: 1100 pg/mL

(normal <50 pg/mL)

Creatinine: 1.5 ng/mL (normal 1.0 ng/mL), patient baseline 1.2 ng/mL

CK: 90 ng/mL

(ref range 40 to 150)

CK-MB: 10.2 ng/mL (ref range 0.0 to 6.9)

cTroponin-I: 0.40 ng/mL

(ref range 0.00 to 0.09 ng/mL)


EKG and chest x-ray are pictured in Figures 2 and 3.

Hospital Course:

Cardiology evaluated the patient after the EKG was performed 10 minutes after arrival. She was started on IV heparin, aspirin, statin, IV furosemide, and IV nitroglycerin in the ER within an hour of arrival. Her blood pressure decreased to 150/80 and her chest pain was relieved once she was started on the IV nitroglycerin. She urinated after being given the furosemide, and her breathing improved with a respiratory rate of 18/minute and O2 sats of 95% on 2L NC.

Your librarian is

Michel Atlas
Kornhauser Health Sciences Library


University of Louisville
500 S. Preston Street Louisville, KY 40292


tel 502.852.5771

fax 502.852.1631

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