HPI (History of Present Illness): Mrs. Hansen is a 78 year-old femalewho presents to the ED with syncope. She tells you “I was out walking this morning when I started to feel lightheaded and sweaty, and then I felt weak and nauseated. Next thing I knew, my neighbor was calling to me. I was lying on the ground. My head and hip really hurt. I guess I bruised them pretty badly.” Mrs. Hansen complains of muscle aches all over her body.Past Medical History: MI (three years ago), she has a stent in her right coronary arteryStable AnginaHypertensionType 2 Diabetes Mellitus (x20 years)Diabetic NeuropathyObesityAnxietyInsomniaIrritable Bowel Disorder Medications (she insists that she takes all daily as prescribed, using a pill box to help her remember):Aspirin, 325 mg, PO, dailyWarfarin, 5 mg, PO, dailyAtenolol, 50 mg, PO, dailyLisinopril, 30 mg, PO, dailyHydrochlorothiazide, 25 mg, PO, dailyLovastatin, 40 mg, PO, bidNitroglycerin, 0.4 mg, sublingually, prnEmpagliflozin, 20 mg, PO, dailyMetformin, 500 mg, PO, three times a day Gabapentin, 300mg, PO, bidTramadol, 50 mg, PO, every 6 hours, prnValerian root, 1 tablet, every evening at bedtime, (unsure of dose) Allergies: none Surgeries:s/p angioplasty with stent placements/p open appendectomy (“in my teens”)s/p hysterectomy for benign indications (30 years ago) Social History/Lifestyle:Widowed, retired schoolteacher, lives alone, frequent weekend visits from daughter, small circle of close friends. Hobbies are playing the piano, walking her small dogs, gardening Habits:Cigarettes: 20 pack-year history, quit 3 years agoAlcohol: occasional cocktails on the weekends with her “girlfriends,” usually no more than 3Exercise: walks daily for 30 minutes, “on my doctor’s orders”Diet: 3 small meals/day which are “healthy”        Breakfast: toast, cereal with skim milk, fruit, grapefruit juice,        Lunch: half sandwich, soup, coffee or tea        Dinner: whole grain pasta, vegetables Physical Examination:BP: 148/92, P: 84, RR: 22, T: 37.3Obese, anxious female in supine positionHead: large ecchymosis over left brow, edema and tenderness over left side of skullPupils: equal, round, reactiveLungs: bilateral fine crackles over lower posterior fieldsHeart: regular rate, rhythm, no murmurs or additional soundsAbdomen: obese, hypoactive bowel sounds, slight tenderness over LLQ                 and epigastrium, non-distended, no rebound or guardingExtremities: 1 edema to ankles, bilaterally, small red ulceration, medial                    aspect of right great toe, diminished sensation in both feetQ1: What might have caused Mrs. Hansen’s syncope?Q2: What work-up should she undergo?Q3: What do you think of her medication regimen?Q4: Using a database, like Micromedex, Epocrates, or Medscape’s Drug Interaction Checker, how many interactions do you find? Which are major?Q5: Given the medication interactions, which parts of this patient’s history and exam have you concerned?Q6: Is this patient on any herbal/alternative medications?Q7: What do you think of the patient’s diet? Be specific about your concerns.Q8: Why do you suppose she is getting Gabapentin? Is this an FDA approved indication for this drug?Q9: At age 78, are her pharmacokinetics altered? How?Health ScienceScienceNursing CON|NUR MISC

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