Question

The patient is a 92-year old male who was just admitted to your med/surg unit through the ED for dehydration, hypokalemia, and gastroenteritis of unknown etiology. His past medical history indicates that he has had COPD for 26 years. His COPD has been characterized by a mixture of emphysema, chronic bronchitis, and reactive airway symptoms. 8 years ago he developed right-sided HF, and after a knee replacement 5 years ago his HF became bilateral, and he developed atrial fibrillation. He has HTN, chronic renal insufficiency, and Type 2 DM. His meds include: 3 inhalers - tiopropium, salmeterol/fluticasone, and albuterol prn; and the following PO meds - digoxin, furosemide, warfarin, prednisone, theophylline, lisinopril, metoprolol, metformin, and glipizide. Upon admission his VS were P 108, RR 32, BP 98/52, T 99, and O2 sat by pulse oximetry 90% on room air. He is oriented, but states he is too tired to answer questions. Lung sounds diminished bilaterally, extra heart sounds noted, bowel sounds hyperactive and high-pitched. His wife states he has had approximately 12 loose BMs in the last day, and that this is the third day of severe diarrhea, nausea, and vomiting. She does not know when the last time he voided was, and states that he has continued to take all of his medications, except his diabetes pills, which he stopped taking because he hasn’t been eating . He also had the following diagnostic results:

ABGs:

pH: 7.25

CO2: 50

HCO3: 25

PaO2: 84

SaO2: 90%

CXR: changes consistent with COPD, enlarged heart

EKG: atrial fibrillation

2-D Echo: left ventricular hypertrophy with 25% EF

CBC & METABOLIC PANEL:

HGB: 19

HCT: 58

WBC: 8

BUN: 59

CREAT: 2.8

Na: 155

K: 2.8

Cl: 110

Ca: 8

PO4: 5.1

Mg: 1.2

Glucose: 987

Pre-Albumin: 15

Albumin: 2.9

Total protein: 4.8

INR: 3.5

Digoxin level: 1.9

Theophylline level: 24

Analyze and explain the rationales for each of these orders listed below (Hint: keep the same things in mind here as when analyzing assessment data). Are there any additional orders that you think would be appropriate? Why?

Orders include:

O2 2L via NC

IV ½ NS with 30 mEq KCL @ 125 mL/hr X 1 liter, then change to NS with 20 mEq KCL @ 75 mL/hr

Regular insulin IV 10 unit bolus, FSBS q 15 min with IV bolus scale until FSBS under 250, then FSBS ac + hs with sliding scale SQ lispro insulin

Clear liquid diet

Heparin 5000 units SQ q 12 hrs

furosemide 20 mg PO daily

lisinopril 10 mg PO daily

metoprolol 50 mg PO BID

inhalers as at home

prednisone 5 mg PO daily

vitamin K 10 mg IM X 1

ondansetron 4 mg IV q 4 hrs prn/nausea

loperamide 2 mg PO q 4 hrs prn/diarrhea

Repeat CBC, basic metabolic panel, & INR in the AM. 24-hour urine for creatinine clearance, stool for OB, C&S, O&P, C Diff.

Answer 1

The patient is an elderly man who is 92 years old with cardiac,lung complications. Other conditions include diabetes and hypertension .

Rationale for the orders include -------

1. Oxygen 2 L via nasal cannula : The patient is maintaining 90 % of SpO2 and hence oxygen was started.

2. IV 1/2 NS with 30 mEq/L KCL : The serum potassium level of the patient is 2.8 which is towards lower side and the person has also lost potassium with the loose stools he had.

3. Regular insulin IV bolus and then as a sliding scale : The patient is known diabetic and is on potassium infusion. Therefore, insulin was started.

4. Heparin 5000 units subcutaneously twice a day : It is an anticoagulant which prevents the clot formation by thinning the blood. Since , the patient has heart failure with atrial fibrillation heparin was started.

5. Furosemide 20 mg daily : it is loop diuretic which prevents the water reabsorption back into the body thereby increasing the urine output. It checks blood pressure levels.

6. lisinopril 10 mg daily: It is angiotensin converting enzyme inhibitor that controls blood pressure and also used in treatment of the heart failure.

7. Metoprolol 50 mg PO :  It is neta blocker which is used in treatment of high blood pressure and chest pain.  

8. Prednisone: The patient is known case of COPD and hence steriod inhalation with prednisone relaxes the Airways and ease breathing.

9. Vitamin K : It prevents any bleeding. Since the person is on heparin, he is at risk of bleeding. Therefore, to prevent it vitamin K is given.

10 . Ondasetron : It is used to prevent nausea and vomiting. The person has gastrointestinal upset and hence it is used.

11. Loperamide : The patient has severe history of diarrhoea. Loperamide reduces the intestinal motility reducing loose stools.

With all these medications repeating the basic blood tests of CBC,INR, serum electrolyte is done AM and then urine test for creatinine clearance, stool for culture and sensitivity, C. Difficile is done to rule out the infection.

Treatment has included all the aspects and hence there is no room for further treatment.

Thank you.