Pathophysiology of Medical History Week 8

Professor Park/Blackard Case scenario for Concept Map # 8 C.W 481L Advance Medical-Surgical The wife of C.W., a 70-year-old man, brought him to the emergency department (ED) at 0430. She told the ED triage nurse that he had diarrhea for the past 2 days and that last night he had a lot of “dark red” diarrhea. When he became very dizzy, disoriented, and weak this morning, she decided to bring him to the hospital. C.W.’s vital signs (VS) in the ED were 70/− (systolic blood pressure [SBP] 70, diastolic blood pressure [DBP] inaudible), pulse rate 110, respirations 22, oral temperature 99.1° F (37.3° C). A 16-gauge IV catheter was inserted and a lactated Ringer’s infusion was started. The triage nurse learned C.W. has had idiopathic dilated cardiomyopathy for several years. The onset was insidious, but the cardiomyopathy is now severe. His last cardiac catheterization showed an ejection fraction of 13%. He has frequent problems with heart failure (HF) because of the cardiomyopathy. Two years ago, he had a cardiac arrest that was attributed to hypokalemia. He has a long history of hypertension and arthritis. He had atrial fibrillation in the past, but it has been under control recently. Fifteen years ago he had a peptic ulcer.

Endoscopy showed a 25- × 15-mm duodenal ulcer with adherent clot. The ulcer was cauterized, and C.W. was admitted to the medical intensive care unit (ICU) for treatment of his volume deficit. You are his admitting nurse. As you are making him comfortable, Mrs. W. gives you a paper sack filled with the bottles of medications he has been taking: enalapril (Vasotec) 5 mg PO bid, warfarin (Coumadin) 5 mg/day PO, digoxin (Lanoxin) 0.125 mg/day PO, potassium chloride 20 mEq PO bid, diclofenac (Voltaren) 50 mg PO tid and tolmedin 600 mg TID. As you connect him to the cardiac monitor, you note he is in sinus tachycardia. Doing a quick assessment, you find a pale man who is sleepy but arousable and slightly disoriented. He states he is still dizzy and feels weak and anxious overall. His BP is 98/52, pulse is 118, and respiratory rate 26. You hear S3 and S4 heart sounds and a grade II/VI systolic murmur. Peripheral pulses are all 2 +, and trace pedal edema is present. Capillary refill is slightly prolonged. Lungs are clear. Bowel sounds are present, mid-epigastric tenderness is noted, and the liver margin is 4 cm below the costal margin. Has not yet voided since admission. Rates his pain level as “2.” A Swan-Ganz pulmonary artery catheter and a peripheral arterial line are inserted.

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Laboratory Results Sodium 138 mEq/L (138 mmol/L) Potassium 6.9 mEq/L (6.9 mmol/L) BUN 90 mg/dL (32.1 mmol/L) Creatinine 2.1 mg/dL (185.6 mcmol/L) WBC 16,000/mm3 (16 x 109/L) Hgb 8.4 g/dL (84 g/L) Hct 25% PT 23.4 seconds INR 4.8

ECG strip showing:

Intensivist ordered Levophed drip to keep MAP>65, Flagyl IV 500 mg q8h, Normal Saline IV fluids 125 ml/h, protonix 40 mg iv push bid. and morphine 1 mg q4h PRN for pain. He also continues pt’s home medications except tolmedin 600 mg TID. Pending orders CXR, KUB, NG tube to suction and Echo.

This morning I found the patient to be A/Ox1 Confused at times. MAE buy unable

to follow commands. He was intubated last night after an episode of Respiratory Failure with a saturation of 82% on a Non rebreather. Lung assessment with crackles, course, and diminished breath sounds. CXR showing bilateral mild pulmonary edema, congestion, and atelectasis. Ventilator setting : Mode AC Rate 12 TV 500 FiO2 90% Peep 5 Pt still on Sinus Tachycardia with a rate of 155. Echo was done with EF 35%. Bowel sounds hypoactive, NPO, NG tube attached to low suction with 350 output of blood like fluid. Foley catheter in place with 10 ml/h. Skin with IAD and edema +4 BLE, and generalized edema. Peripheral IV Left wrist and PICC line LUE, 3 lumens. Patient now in Levophed 9 mcg/min, Protonix IV 8mcg at 10 ml/h, Sandostatin IV drip 0.5mg/h, Reglan IV Push 10 mg BID,Zosyn Iv 3.375 gm IVPB q 8 hours. Labetalol 50 mg NG BID, lisinopril 40 mg Ng BID, Lopressor IV push 10 mg q4 hour for HR>160, plus home medications.

Lactic Acid 2.1 2.8 3.5 Procalcitonin 1.5

CBC: WBC 25 Hgb 6.5 Hct 19.6 Platelets 112 INR 4 Blood culture + Gram +Cocci BMP: Na 135 k6.7 Chloride 99 BCarb 21 Bun 31 Crat 1.87 Glucose 214

Mg2.1 PO4 2.4 BNP155 Ammonia11 A1C 7.8 UA + Troponins 0.8 0.12 0.10 ABGs PH 7.27 PCO2 37 PO2 58 HCO3 19.8 Sat 83% RA CT of Head: No evidence of Acute Intracranial pathology. Renal Ultrasound: Thick walled bladder compatible with urinary obstruction.

Case management came to interview the patient and wife to plan for discharge and found out that the patient lives at home with his wife. He has 1 adult son, one daughter and 1 grandchild. C,W practices Judaism and goes with his wife to the synagogue every Saturday. He owns a business that provides income to support his family. Due to his disease, the patient has not been able to take care of his business and now they are in a financial crisis. C.W has a great support system, but he wants to be independent and does not want to ask for help

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