Question

Case Study

Amnah is a 55-year-old female patient who has been admitted to the medical ward with acute shortness of breath, chesty cough, wheezing and chest discomfort. Amnah’s vital signs were: SpO2 82% on room air, BP 150/90 mmHg, Pulse 110 beats/min, RR 28 breaths/min, and Temperature 38.7 °C. Amnah has a history of COPD and hypertension for 15 years. She was also diagnosed with heart failure 2 years ago. While doing the physical examination, the patient seemed to use her accessory muscles and have cyanosis in the lips and nose. She also started to get mixed up during the nursing assessment as she could not figure out that she was in the hospital. Amnah also complaint of weakness and fatigue and her lower limbs were very edematous. After a medical review, ABG was taken, CXR was done and venous blood samples were sent for complete blood count, chemistry and culture and sensitivity. Amnah’s lab results were as follows:

Chemistry	Patient Value	Normal Values	ABG & CXR
Sodium	148	136-146 mmol/L	pH 7.25 PaO2 49mm Hg PaCo2 58mm Hg HCO3 27mEq/L
Potassium	4.4	3.5-5.3 mmol/L
Chloride	106	98-108 mmol/L
BUN	68	7-22 mg/dl
Creatinine	1.66	0.7-1.5 mg/dl
Blood culture and sensitivity	streptococcus pneumoniae		CXR: opacity of right lower loop with consolidation and pleural effusions with cardiomegaly
Calcium	7.8	8.9-10.3 mg/dl
Phosphorus	10.4	2.6-6.4 mg/dl
Alkaline Phosphatase	321	30-110 IU/L
Hemoglobin	14.5	14-17 gm/dl

Based on the medical review and the diagnostic tests results, Amnah was mainly diagnosed with impaired respiratory functions. She was also found to have some cardiac and renal abnormalities. The doctor ordered immediate treatment and requested very close monitoring of Amnah.

1. Amnah was diagnosed with health issues other than respiratory. Identify two of these issues and give one diagnostic finding for each?

Answer 1

Amnah, 55years old female admitted with complaints of acute shortness of breath, chesty cough, wheezing and chest discomfort.

Examination findings include : SPO2 - 82% on room air, BP- 150/90 mm of Hg, Pulse - 110/minute, RR - 28.

History shows that she is having COPD & hypertension for 15 years and heart failure for 2 years.

On Physical Examination, it is found that she often loses orientation to place, uses accessory muscles of respiration and has central cyanosis. She complaints of weakness and fatigue. There is edema in the lower limbs.

Her relevant lab investigation findings include the following :

ABG values : pH - 7.25

PaO2 - 49 mm Hg

Pa CO2 - 58 mm Hg

HCO3 - 27 mEq/L

Sodium - 148 mEq/L

BUN - 68 mg/ dl

Creatinine 1.66 mg/dl

Blood culture & sensitivity : Streptococcus pneumoniae

Chest Xray : consolidation and pleural effusion with cardiomegaly

Phosphorus 10.4 mg/ dl

Alkaline phosphatase 321 IU/L

From all these history, physical examination and lab findings, we can conclude the following

1. Severe respiratory impairment : findings are complaints of shortness of breath, wheezing, chest discomfort, chesty cough, laboured breathing, cyanosis, hypoxemia. Blood culture and sensitivity result shows Streptococcus pneumonia infection. Chest X ray shows consolidations and pleural effusions with cardiomegaly. She has history of COPD for 15 years.

2.Cardiac impairments : Amnah is hypertensive and known case of COPD for 15 years. She had heart failure before 2 years. Now she has weakness , fatigue and edema in lower limbs. Long history of COPD and hypertension places her at risk of development of cor pulmonale. Chest X ray shows cardiomegaly.

3. Her ABG values shows respiratory acidosis here the pH is 7.25 ( normal level is 7.35-7.45) indicating acidosis, PaCo2 is elevated i.e 58 mm of Hg ( nirmal level is 38-48 mm Hg).That shows respiratory acidosis.PaO2 is very low i.e 49 mmHg (normal level is 75-100 mmHg).And cabonic acid remains within normal limits, which shows it is not metabolic acidosis.

4. Renal abnormalities : There is edema in her lower Limbs. The serum sodium level is elevated. There is high level of blood urea nitrogen, and serum creatinine level is also elevated. All these indicates some abnormalities in the Kidney function. Also the Phosphorus level is elevated that may be due to some impairment in the renal function. Elevated Phosphorus level also can lead to some confusions in the client.

Elevated Alkaline phosphatase level indicates problems in liver, gallbladder or bones. Rarely it can indicate heart failure, kidney problems, cancers or bacterial infection.