SITUATION: Jessie Diaz, a descendant from Mexico, has a significant medical history of cardiopulmonary disease. Jessie was transported by ambulance to the emergency department for increasing shortness of breath, worsening productive cough of thick pink mucus, and edema of the lower extremities that began 19 days ago. Per protocol, vital signs and continuous cardiac monitoring were initiated upon arrival at the emergency department. Blood work for arterial blood gases has resulted. Successfully intubated (#6 Shiley) and vented: FiO2 is 65%, PEEP 5cmH2O, respiratory rate 22 breaths/min, and tidal volume 6-8 mL/kg. Vital Signs Time 1400 Temp 99.14 F (37.2 C) P 126, irregular RR 38 B/P 102/50 MAP 67 Pulse oximeter 76% RA Laboratory Report
Lab Results Reference range ABG pH 7.31 7.35-7.45 ABG PaO2 64 80-100 mmHg ABG PC02 52 35-45 mmHg ABG HC03 19 22-26 mEq/L
BACKGROUND: Social History: Jessie has a 38-pack/year history of smoking and drinks wine socially. The family with Jessie denies substance use. * Jessie’s sole source of income is social security. Medical History: Bronchitis with Pneumonia (2008, 2018)
• Jessie required a tracheostomy for ventilation management in 2018; the initial trach was downsized and removed to health while participating in acute rehab.
DVT (2008, 2018) Diabetes Mellitus Atherosclerosis and hyperlipidemia Coronary Artery Disease with non-STEMI MI (2010) Surgical History: Internal fixation repair of ankle fracture following MVA 15 years ago Tracheostomy (2018)
Medications Empagliflozin 10 mg PO daily Sitagliptin / metformin 50-1000 mg PO daily Valsartan 160 mg PO daily Clopidogrel 75 mg PO daily Atorvastatin 20 mg PO daily at bedtime Advair Discus twice daily
Assessment: Day of Admission: Jessies is admitted to the intensive care unit (ICU) with Acute Heart Failure and a new onset of Atrial Fibrillation with Rapid Ventricular Response (RVR). A Dexmedetomidine drip was started for sedation; Amiodarone for drip for atrial fibrillation; Heparin for DVT prophylaxis; and Pantoprazole for gastric ulcer prophylaxis. Day 2 – 1400 Cardiac monitoring continued with normal sinus rhythm with occasional PVC and PACs. A nasal swab for MRSA is positive, and contact precautions started. Crackles were noted in the posterior lung bases, and increased edema in the lower and upper extremities. Furosemide drip was initiated with a goal of an hourly negative fluid balance of 100 mL. Tube feedings started at 20 mL/hr and are to be increased by 20 mL every 6 hours to a goal of 55 mL/hr. The dexmedetomidine drip was discontinued. Intermittent Midazolam and Hydromorphone, PRN administered. Day 3 – 1000 SBT unsuccessful. A chest tube was inserted under local anesthesia, connected to a water seal and negative wall suction, and continued on the vent. Chest XR results show a 15%pneumothorx in the apex of the right lung. Day 4 – 1130 Enteral nutrition continued, now at goal. Clients remain in NSR x3 days. The Heparin drip was discontinued, and subcutaneous Heparin daily for DVT prophylaxis started. The Furosemide drip was stopped, and administered Furosemide 80 mg was every 12 hours. The chest tube remains intact with bubbling in the water seal chamber. Blood sugars are elevated; started on insulin sliding scale and insulin drip per protocol. Day 5 – 1800 SBT was successful, and the client was changed to a trach collar, #4 Shiley. Insulin drip was discontinued and started on 18 units of Lantus at bedtime with continued sliding scale coverage. Chest tube downgraded, removed from wall suction. Hourly bedside rounds continued. The client is upright in bed with feet hanging from the side in a seated position. Day 6 – 1200 Lung fields clear anterior/posteriorly. Chest tube removed, started on Warfarin 3 mg. The client transferred to Surgical Step Down. Enteral nutrition continued. Chest tube intact, no blood noted in the drainage. Day 7 0930 During the handoff report, the client complained of right leg pain; MD was made aware, and a venous doppler was ordered, resulting in a DVT at the popliteal vessel. Weight-based Heparin drip started. Sitagliptin/Metformin 50-1000mg PO was ordered with sliding scale insulin coverage. Lung fields remain clear anteriorly/posteriorly. The client will be evaluated by PT and plan for discharge to rehab in two days. ` Day 10 The client will be discharged to subacute rehab on home medications. Discharge teaching provided; the client will continue on Warfarin 3mg PO daily with weekly INRs. The client was advised to follow up with a primary healthcare provider.
LAB RESULTS
Lab Result ICU Admission Day 2 0630
Day 4 0630
Day 6 0630
Day 10 0630
Sodium 139 mEq/L 139 mEq/L 130 mEq/L 132 mEq/L 135 mEq/L
Potassium 4.6 mEq/L 3.6 mEq/L 3.2 repeated to 4.1 mEq/L 4.2 mEq/L 4.0 mEq/L
Chloride 97 mmol/L 99 mmol/L 98 mmol/L 99 mmol/L 98 mmol/L
CO2 27 mmol/L 34mmol/L 32 mmol/L 33 mmol/L 35 mmol/L
Calcium 8.5 mg/dL 7.4 mg/dL 8.7 mg/dL 8.2 mg/dL
Phosphorus 4.3 mg/dL 3.6 mg/dL 3.2 mg/dL repeated 3.7 mg/dL
Glucose 235 mg/dL 198 mg/dL 225 mg/dL 178 mg/dL 152 mg/dL
BUN 34 mg/dL 42 mg/dL 48 mg/dL 35 mg/dL 33 mg/dL
Creatinine 1.4 mg/dL 1.6 mg/dL 1.7 mg/dL 1.5 mg/dL 1.4 mg/dL
Total Cholesterol 230 mg/dL 218 mg/dL
LDL Total 196 mg/dL 186 mg/dL
HDL 44 mg/dL 45 mg/dL
ALT 28 U/L
AST 31 U/L
Troponin I 2.4 ng/mL 0.9 ng/mL
NT-proBNP 242 pg/mL
WBC 15,100/mm3% 17,400/mm3% 19.8/ mm3% 14.1/ mm3% 10.2/ mm3%
Hgb/Hct 8.7/26.2
Platelets 141/mm3 133/mm3 114/mm3 128/mm3 142/mm3
PTT 62 sec 38 sec 31 sec
PT/INR 15 sec/1.2 14 sec/1.4 32 sec/2.4
Chest X-ray RUL infiltrate
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