History of Present Illness
A 59-year-old male was brought to the Emergency Department via emergency medical services (EMS). His wife states she came home from work and found him lying on the bathroom floor face down. She immediately called 911. She reports that she was able to feel a pulse and states he was breathing but “taking very shallow breaths.” EMS arrived on the scene within 3 minutes and transferred him to the Emergency Department. He was stabilized by the ED staff and is being transferred to your care in the Critical Care Unit.
Past Medical History
Client has a history of hypertension regulated with medications.
Past Surgical History
Appendectomy at age 28 and right knee arthroscopy at age 36.
Father, 82, alive with hypertension, diabetes and arthritis; mother, 78, alive with hypertension, diabetes and chronic renal failure; son, 27, alive with no known medical history; daughter, 25, alive with no known medical history.
High school graduate. Retired machinist from the Army after 20 years of service. Currently unemployed. Lives with wife and daughter. Denies any religious affiliations. Reports smoking 1 pack of cigarettes per day and has been smoking since he was 17 years old. Drinks 6-12 beers per day for the past couple of years and smokes an “occasional marijuana joint”. Denies any other illicit drug use.
Penicillin – causes full body rash/hives.
Hydrochlorothiazide 12.5mg PO once a day.
Lisinopril 40mg PO once a day.
Review of Systems
General: Difficulty concentrating. Complains of occasional bouts of confusion and frequent insomnia. Denies fever or chills. Reports gaining around 15 pounds in the past 2 months.
HEENT: Noted mild generalized headache on rising in the morning, occurring most mornings for at least the past month or two. No associated nausea or vomiting.
Respiratory: Mild shortness of breath with rest and activity. Denies having a cough or chest pain. Denies any form of exercise due to shortness of breath.
Cardiovascular: Has occasional heart palpitations. Denies any chest pain or edema in extremities. Has blood pressure checked at the drug store about once a month, and the last reading was 129/68 mmHg.
Abdomen/GI: Eats three meals a day which consist of a “meat and potatoes” type of diet. Complains of constipation on occasion. Complains of bloating that “won’t go away” over the past few weeks. Denies nausea and vomiting. Denies any abdominal pain. Stool is firm, dark, blackish color.
GU: Denies dysuria, urgency or hesitation.
Musculoskeletal: Complains of numbness and tingling in finger tips on occasion. States he has developed a “mild shake” in his hands which started about 6 months ago. Denies any joint or bone pain.
Neuro: No history of seizures. Difficulty concentrating. Headache in the mornings, numbness and tingling in fingertips. Denies trouble with speech, trouble swallowing, or any other neurologic problem.
Psych: Is depressed with current life due to inability to find a job. Wife is supportive.
VS: T – 98.2oF oral, HR – 125 bpm/regular, R – 42, BP – 90/52 mmHg supine, Pulse ox – 90% on room air. Ht. 5’7″ Wt. 194 lbs.
General: Listless, well-developed man who appears his stated age. Interactive when stimulated.
Skin: Warm, dry, yellow in color. Ecchymosis noted on bilateral upper extremities. Petechiae noted on anterior trunk.
HEENT: Normocephalic; PEERLA; scleral icterus; oropharynx clear. Neck supple, full painless active and passive ROM. Trachea midline, no lymphadenopathy or thyroid enlargement. Carotid pulse bounding, no bruits.
Chest: Lung sounds diminished on auscultation with crackles at the bases. No chest asymmetry noted.
Cardiovascular: No abnormal heart sounds, heaves or thrills; no clubbing or cyanosis. Bilateral extremity pitting edema 2+ noted. Peripheral pulses equal and +1 throughout.
Abdomen/GI: Abdomen round and firm. Bowel sounds hypoactive in all 4 quadrants. Tympany over umbilicus with dullness over lateral and flank areas of abdomen. Abdomen distended.
GU: Bladder not palpable. Normal male genitalia.
Musculoskeletal: Full ROM in all joints; no swelling or crepitus. Bilateral strength equal in upper and lower extremities.
Neuro: Listless, oriented x 2 (person and place only), cranial nerves II-XII intact. Deep tendon reflexes 2+ throughout, negative Babinski.
What information in the history/physical would support a diagnosis of possible Liver failure?
Record your thoughts here.
2. Is there another diagnosis that you might suspect? (CHF – edema, crackles, tachycardia, tachypnea & hypotension)
Record your thoughts here.
The following admission orders were given to the nurse for the client.
Admit to CCU
Labs: CBC, BMP, Bun/Cr, Ammonia, Serum Albumin, PT/INR, PTT, Blood alcohol
12 Lead ECG
Call provider with results.
Continuous pulse oximetry
Vital signs every hour
Oxygen via NC to maintain SpO2> 92%
Strict Intake and Output
0.9% NS 500mL IV bolus, then 200mL/hr continuous infusion
3. After reviewing the orders and physical exam be prepared to list the top four orders to implement after CCU admission.
Record your thoughts here.
Initial Lab Values
LAB Normal Range 10/02/17 1847
WBC 4.5 – 11.0 x 109/L 12
Hgb 13.5 – 17.5 g/dL 11
Hct 36 – 47% 30%
Platelets 150 – 450 x 109/L 45
Na 135 – 145 mEq/L 130
K 3.5 – 5.0 mEq/L 3.3
Cl 98 – 106 mmol/L 107
BUN 7 – 20 mg/dL 45
Cr 0.6 – 1.2 mg/dL 1.2
Bicarbonate 23 – 29 mEq/L 24
Glucose 70 – 140 mg/dL 50
Calcium 8.5 – 10.2 mg/dL 9
Mg 1.5 – 2.5 mEq/L 3
Phos 2.5 – 4.5 mg/dL 4.5
PT 11 – 14 sec 20
INR 0.8 – 1.2 1.7
PTT 25 – 35 sec 54
Albumin 3.5 – 5.5 g/dL 2.4
NH4 15 – 45 mcg/dL 45
< 0.01g/dL 0.08 = legal intoxication limit 0.2 4. After reviewing the initial lab values and the physical exam of the client, what lab(s) would be most concerning to the nurse and why? Record your thoughts here. ____________________________________________________________________________________________________________________________________________________________ 5. What is your rationale for choosing the labs you chose? Record you thoughts here. ____________________________________________________________________________________________________________________________________________________________ Arterial Blood Gases: pH 7.48; PaCO2 28; PaO2 60; HCO3 24 6. Interpret the above ABG results. ________________________________________________________________________________________________________________________________________________________ 12 Lead ECG 7. Interpret the 12 Lead ECG above. Record you thoughts here. __________________________________________________________________________________________________________________________________________________ The provider has decided the client needs an endoscopy STAT. You have received orders to prep the client for the endoscopy that is scheduled in 2 hours. After your last assessment you report the client has not urinated since admission despite the fluid bolus and maintenance fluids. The provider has ordered another NS fluid bolus of 500mL/hr and an indwelling foley catheter to be inserted to measure strict Intake and Output. 8. What do you suspect is the main reason the provider ordered an endoscopic study? Record your thoughts here. __________________________________________________________________________________________________________________________________________________ 9. Why do you believe the provider ordered an additional NS bolus? Record your thoughts here. __________________________________________________________________________________________________________________________________________________ After the additional NS bolus was infused, the nurse notes these VS: RR 40 breaths/min, HR 99 bpm, BP 97/62 mmHg supine, SpO2 92% on 6L NC. Lungs are diminished at the apices and crackles are auscultated throughout the lower lobes about ½ way up the lungs bilaterally. Urine output increased to 15mL/hr. 10 The nurse calls the provider and reports the new assessment findings. What would the nurse expect to be ordered for the client? Record your thoughts here. The nurse has received a phone call from the endoscopy department that they will be sending for the client shortly. As the nurse hangs up the phone, the wife runs out of the room because the client is vomiting "dark brown stuff". The nurse runs into the room and finds the client lying in bed with coffee ground emesis all over him. 11. What might the clinical signs and symptoms indicate? Record your thoughts here. __________________________________________________________________________________________________________________________________________________ The nurse notifies the provider and the client is sent immediately to endoscopy for a scope. The endoscopy procedure was not able to visualize anomalies in the lining of the stomach but was able to determine the client had several varicose veins in the lower part of his esophagus which were banded during the procedure. 12. What are your thoughts about the varicose veins being banded? Record your thoughts here. _____________________________________________________________________ _____________________________________________________________________ The provider ordered CBC q 8 hours x 3 and a type and crossmatch. See results below: LAB Normal Range 10/02/17 1847 10/02/17 2218 10/03/17 0415 10/03/17 1022 WBC 4.5 - 11.0 x 109/L 12 11.6 11.2 11 Hgb 13.5 - 17.5 g/dL 11 10.2 8.6 7.7 Hct 36 - 47% 30% 28% 24% 22% Platelets 150 - 450 x 109/L 45 45 43 42 13. Prioritize your top concerns/problems for this client and your rationale for the prioritization. Record your thoughts here. ___________________________________________________________________________________________________________________________________________________________________________________________________________________________
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