Question

History of Present Illness:

60-year-old male with past medical history of alcohol abuse, COPD/emphysema and reflux esophagitis in the past presents to the emergency department

with c/o severe shortness of breath going on for the past 5 days. Patient states that he was at home and has not left his home. Patient states he lives with

his brother and his brother have not left the home because they are both following the guidelines to stay at home. His brother has a girlfriend that visits 2 to

3 times a week but she has not been showing any symptoms of any illness. Patient states that he nor his brother or the girlfriend have had fever, chills, diarrhea,

nausea, or vomiting. Patient has a known history of COPD and has had numerous exacerbations in the past. Patient states that he was deteriorating at home so

his brother called EMS to bring him to the hospital. Patient was brought to the ER and was found to be severely hypoxemic and was placed on high-flow oxygen

and had an elevated lactate acid. Chest x-ray did not show any consolidation. Patient did not have a fever, denied having chills, nausea, vomiting, headache,

blurry vision, diarrhea, or constipation at this time.

Review of Systems

Constitutional: Negative except as stated in HPI, no fever, no chills, no sweats.

Head: negative

Eyes: negative

Ears/nose/mouth/throat: negative

Respiratory: negative except as stated in HPI

Cardiovascular: Sinus tachycardia on monitor, regular rhythm

GI: negative

GU: negative

Immunologic: negative

Musculoskeletal: negative

Integumentary: negative

Neurologic: Alert and oriented to person, time, and place

Objective:

Temperature: 102.3 degrees F, HR: 120, respirations: 26, BP: 146/84, SpO2: 87%, Wt: 75Kg, BMI: 24.40

Admit: 03/09/2020                                                                                  Patient name: Michael Bloomsmith

Room: 302    Bed A

DOB: 09/22/1957                                                                                    Admitting Physician: Dr. Mo Parks

Sex: Male

Health History

Alcohol abuse

Back pain

COPD

Hernia

Hypertension

Pneumonia

Problem List per patient

Alcohol abuse

Emphysema/COPD

Hiatal hernia reflux

Esophagitis

Medications

Patient reports taking no medications at home

Allergies: NKA

Social History

Smokes 2 packs/day

Admits to drinking beer weekly

Denies illicit drug use

Physical Exam

General: alert and oriented, respiratory distress on high-flow nasal cannula

HEENT: Normocephalic

Respiratory: Severely diminished lung sounds bilaterally with mild wheezing

Cardiovascular: tachycardic, regular rhythm

Gastrointestinal: soft, nontender, non-distended

Genitourinary: no costovertebral angle tenderness, no Foley

Musculoskeletal: no clubbing, cyanosis or edema

Extremities: No significant deformity or joint abnormality

Integumentary: intact

Neurologic: alert, cranial nerves intact

Psychiatric: Appropriate mood & affect, AAO X 3

Assessment/Plan

Acute hypoxic respiratory failure: likely secondary to COPD exacerbation. Chest x-ray is negative for any chest consolidation. Start patient on high-flow oxygen, continue IV steroids q 8 hours, ceftriaxone, azithromycin continued.

Acute exacerbation of COPD: Nebulizer treatments, steroids and antibiotics

Severe sepsis: continue IV fluids, patient given bolus of fluid in the emergency department; continue at 75cc/hour. Trend lactic acid until less than 2, IV antibiotics, blood cultures

Hypokalemia: Replace per protocol

Hypomagnesemia: replace per protocol

Hyponatremia: Continue IV fluids

Elevated troponin: likely secondary to demand ischemia from hypoxia

Tobacco withdrawal: start nicotine patch

DVT prophylaxis: SCDs/Lovenox

Medications (Inpatient)

Duoneb, 3mL, NEB q 4 hrs

Enoxaparin 30mg twice daily subcu X 7 days

Methylprednisolone 40mg IVP, q 8 hours

Nicotine 21mg/24 hr transdermal film, extended     release, topically every hs.

IV 0.9NSS at 75cc/hour

Ceftriaxone 1 gram IM daily

Azithromycin 500mg IVPB daily

Potassium replacement per protocol

Magnesium replacement per protocol

Estimated length of stay: 4-6 days

Labs:

pH: 7.40

PCO2: 45.7

pO2: 52.8

HCO3: 28.6

O2 saturation: 82%

Hgb: 14.6

Hct: 41%

Platelets: 150

Neutrophils: 13.1

Lymph: 1.7

Mono: 1.3

Eosinophils: 0.0

Basophils: 0.0

Sodium: 130 mmol/L

Potassium: 2.8 mmol/L

Chloride: 78 mmol/L

CO2: 26 mmol/L

AGAP: 26

Glucose: 118 mg/dL

BUN: 13 mg/dL

Creatinine: 0.72 mg/dL

BUN/Creatinine ratio: 18.1

Calcium: 10.0 mg/dL

Est. CrCl: 106.0 mL/min

GFR: 100 ml/min

Albumin: 3.8

Total Protein: 6.3 g/dL

Magnesium: 0.6 mg/dL

Troponin T QuaNT High Sensitivity: 37 ng/L

Alk Phos: 44 units/L

Lipase: 10 units/L

AST: 86 units/L

ALT (SGPT) 107 units/L

Bili Direct: 0.5 mg/dL

Bili Indirect: 0.6 mg/dL

Lactic Acid: 3.9 mmol/L

Adenovirus: not detected

Chlamydia pneumoniae PCR: not detected

Coronavirus PCR: not detected

Coronavirus PCR: not detected

Influenza B: not detected

Influenza A: not detected

Mycoplasma pneumoniae PCR: not detected

RSV A PCR: not detected

RSV B PCR: not detected

Radiology: No acute pulmonary parenchymal or pleural pathology

Tasks:

1. Which of the above labs are abnormal?
2. Correlate the abnormal labs with the client’s current or past medical problems
3. Choose the corresponding medication for each of the client’s medical diagnoses
4. Compare the methods of administration for the antibiotics and decide why different routes for administration were ordered. Refer to your drug guide.
5. How will you mix and administer the ceftriaxone?
6. Mr. Bloomsmith develops edema on his 4^th day of hospitalization and the IV fluids are discontinued. The physician orders furosemide 80mg IV push. The availability of furosemide is 100mg/10ml. How much furosemide will you administer? How will you administer the furosemide through his capped peripheral site?

Answer 1

●The following lab values are abnormal

• PCO2:Slightly increased 45.7 (35 to 45mmHg)
• pO2:Decreased 52.8 (75 to 100)
• HCO3: Increased 28.6(22_26)
• O2:Decreased 82%(>90%)
• HCT:Decreased 41%(45_52%)
• Neutrophils:Increased 13.1(1.5_8)
• Monocyte:Decreased1.3(2_8)
• Decreased sodium
• Decreased potassium
• Decreased chloride
• AGAP:increased 26 (3_10mEq/L)
• BUN/Creat ratio increased
• Magnesium decreased0.6 (1.7_2.2 mg/dl)
• Increased AST ,ALT
• Increased direct and indirect bilirubin
• Increased Trop T levels
• Increased lactate levels

●The abnormal lab values are correlated to the disease condition in the following ways

• COPD,shortness of breath ,hypoxemic,pneumonia:has led to alteration in the carbon dioxide, oxygen level and oxygen saturation in blood
• Increased liver enzyme is because of alcohol abuse
• Increased body temperature due to infection ,altered WBC count
• Hypertension with oxygen deprivation can have led to ischemia of heart muscle and increased trop t level
• Infection in blood leading to increased lactic acid
• Electrolyte imbalance due to acid base imbalance

●The corresponding medication are

• Hypertension:Enoxparin
• COPD:Duoneb , methylprednisolone
• Pneumonia :Ceftriazone ,azithromycin
• Smoking:nicotine patch
• Hypokalemia, Hypomagnesimia:replacement of potassium and magnesium

●The two drugs can interact and lead to adverse events when given intravenously. If both are choosen to be administered via IM then azithromycin cannot be given by this route which can cause hematoma at the site of administration.

Therefore ceftriazone can be given by intramuscular method and azithromycin by intravenous route.

●Ceftriazone has to be added with 0.9ml of sterile water to achieve the quantity of 1ml. After adding sterile water to the vial (drug available in powder form) roll it in between the palms to mix well and then withdraw to administer intramuscularly

●Given

Order:Furosemide

Dose:80mg

Route:IV

Available:100mg/10ml

When 100mg=10ml

The mb 80mg=??ml

Cross multiply and divide

=80×10÷100

=800÷100

=8

Ans:Administer 8ml of the drug by unlocking the peripheral cap by first injecting normal saline to ensure patency them administer furosemide and again flush with normal saline and recap 9t.