Answered: 1. What are the major concerns for Mrs.…

Phlebotomy Essentials

6th Edition

ISBN:9781451194524

Author:Ruth McCall, Cathee M. Tankersley MT(ASCP)

Publisher:Ruth McCall, Cathee M. Tankersley MT(ASCP)

Chapter1: Phlebotomy: Past And Present And The Healthcare Setting

Section: Chapter Questions

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Transcribed Image Text:Čase Study B Subjective Medical History Mrs. HK is an 84 yr old active woman with a history of hypertension and hyperlipidemia for which she takes hydrochlorothiazide (12.5 mg), simvastatin (10 mg), and 81 mg aspirin daily. She has been experiencing progressive weakness, particularly in her legs, and associated breathlessness when she is active. She states, "I can't seem to do as much as I could two years ago." While still independent in all ADLS, she is no longer comfortable walking with her friends and tends to stay home watching television. Last month, while she was carrying groceries to the car, she became so weary that she almost fell as she stepped from the curb. Her weight has been stable. She has no other constitutional 2 From J.K. Ehrman, P.M. Gordon, PS. Visich, and SJ. Keteyian, Clinical Exercise Physiolagy Web Resource, 4th ed. (Champaign, IL: Human Kinetics, 2019). complaints. She is compliant with her medications, eats a well-balanced diet, and has been sleeping reasonably well. Diagnosis Recently, on the advice of her children, Mrs. HK went to see her internist. Her exam was normal, including BP 142/70 mmHg on her medications, heart rate 72 beats - min, and BMI 22 kg - m?. The lipid profile showed total cholesterol of 170 mg - dL, with LDLC 102 mg - dl, TG 80 mg - dL, and HDL 32 mg - dL. The internist noted a normal physical exam, although the ECG showed left ventricular hypertrophy with a strain pattern. He ordered an exercise stress test to explore the possibility that cardiac ischemia was the cause of her symptoms. Since the baseline ECG was abnormal, he ordered that sestamibi radionuclide imaging be included to ensure better diagnostic specificity. Objective and Laboratory Data Exercise Test Results Mrs. HK walked 6 min on a modified Bruce protocol, achieving 5 METS. Peak HR was 152 beats - min, and peak BP was 170/70 mmHg. There were no additional ECG changes and no significant ventricular or supraventricular rhythm abnormalities. However, radionuclide imaging showed a small area of reversible inferior wall ischemia. Mrs. HK's doctor added metoprolol (12.5 mg twice daily) to her regimen and raised her simvastatin from 10 to 20 mg. He told her that if things did not improve, he would likely recommend a heart catheterization. Over the next few weeks she experienced more fatigue plus myalgias and lapsed into even greater inactivity. Despite some initial apprehension, she is now inclined to undergo a heart catheterization since she believes it will help improve her exercise capacity, quality of life, and presumably her longevity. Assessment and Plan Exercise Prescription While morbidities such as coronary artery disease are likely to occur in the elderly, especially in the context of chronic hypertension and hypercholesterolemia, her progressive exercise decline does not necessarily indicate that coronary artery disease is the cause or that she will benefit from revascularization. Moreover, the recently

Assessment and Plan
Exercise Prescription
While morbidities such as coronary artery disease are likely to occur in the elderly,
especially in the context of chronic hypertension and hypercholesterolemia, her
progressive exercise decline does not necessarily indicate that coronary artery disease is
the cause or that she will benefit from revascularization. Moreover, the recently
published COURAGE trial (4) indicates that even if patients like Mrs. HK are
revascularized percutaneously by coronary stents, they will not live longer.
Instead, Mrs. HK will likely benefit from an exercise training program, one that is inclusive
of strength training in association with aerobic, flexibility, and balance training. While
issues of coronary artery disease as well as iatrogenic medication effects can complicate
training goals, they do not preclude training. In Mrs. HK's case, side effects of B-blockers
and statins are often temporary, but they need to be carefully monitored over time,
especially in association with an exercise training regimen.
3 From J.K. Ehrman, P.M. Gordon, P.S. Visich, and S.J. Keteyian, Clinical Exercise Physiology Web Resource, 4th ed.
(Champaign, IL: Human Kinetics, 2019).
A clinical exercise physiologist will need to be cognizant of Mrs. HK's multiple medical
disorders and medications superimposed on age-associated physiological changes and
the inevitable dynamics of her own hopes and frustrations and those of her children.
Exercise must begin at low levels and progress in small increments to ensure that the
regimen is well tolerated and that it addresses the spectrum of needs underlying her
functional limitations and health requirements.
Case Study Discussion Questions
1. What are the major concerns for Mrs. HK during exercise activity?
2. Based on Mrs. HK's medical history and living situation, what are important barriers to
her continued participation in the physical activity program?
3. What special precautions were likely taken during her exercise test?
4. What motivational strategies can be used to ensure her exercise adherence? 5. What are
the major risks of Mrs. HK's participation in an exercise program? 6. What might be
appropriate recommendations for advancing Mrs. HK to walking three times a week for 30
min or on a daily basis?

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