TMC Operating Room

Prof. Acena

HYPOTHETICAL CASE STUDY FOR ACUTE BIOLOGIC CRISIS Patients Name: AGB Age: 71 y/o Status: Widow, with 3 child en !eldest "# y/o$ %nd& "%$ youngest 37 y/o' (ccu)ation: (wne , ga ment com)any *ousehold income/month less deductions: %"+,+++/month Add ess: 1,- San .oa/uin St, 0o est *ills, 1aytay 2i3al 4ate o5 Admission: 6este day at 3:3+)m ASSESSMENT UPON ADMISSION: Present Health History: AGB is a 71&yea &old 0ili)ino male with dia?etes that is well cont olled with medication: *e has had occasional, t ansient e)isodes o5 chest tightness o;e the last two weeCs, and the tightness etu ned one day while he was 5i9ing his ca in the ga age: Since the )ain didnt seem to ?e going away, he decided to call his docto : 1he docto s ece)tionist had AGB s)eaC with the nu se, who asCed AGB a?out the /uality and location o5 the chest tightness: AGB e)lied that the tightness 5elt liCe a ?and ac oss the cente o5 his chest, with )ain adiating th ough his le5t a m 5o a 5ew seconds ?e5o e su?siding: *e added that this )a ticula e)isode o5 chest tightness was t igge ed ?y e9e tion while doing ?acCya d/ga age wo C, and that he had had a cou)le o5 ecent e)isodes while walCing ? isCly u)hill: 1he nu se, sus)ecting that AGBs angina might ?e a sign o5 an imminent hea t attacC, asCed him i5 he has a elati;e who can ? ing him to the hos)ital as he might ?e ha;ing a hea t attacC: AGB and his youngest son went to the eme gency oom, whe e a team o5 )hysicians and nu ses was waiting to administe the eme gency de)a tment ) otocol 5o a sus)ected myoca dial in5a ction: Past Health History: 7n5ectious 4iseases: 8sual childhood illnesses e9)e ienced: No histo y o5 heumatic 5e;e : 7mmuni3ations: 0lu ;accine yea ly c/o Senio <iti3en& Pneumo;a9 $ Alle gies: Alle gic to Penicillin&de;elo)ed a di55use ash a5te an in=ection , "+ yea s ago *os)itali3ations, ()e ations, 7n=u ies: 4> 1y)e 77 since >ay %++3 and was admitted in Se)tem?e %++# 5o 8nsta?le Angina @ *y)e tension: Physical Exam: 1. Vital Signs: BP1-+/1++ lying down$ 1em)e atu e 3,:% +< Pulse A, egula with occasional e9t a ?eat, 2es)i ation %" 2. HEENT: Byes: e9t aocula motions 5ull, g oss ;isual 5ields 5ull to con5 ontation, con=uncti;a clea : scle ae non&icte ic, )ul)ils e/ual ound and eacti;e to light and accomodation, 5undi not well ;isuali3ed due to )ossi?le ) esence o5 cata acts: wea s eading glasses ?ut thinCs ;ision is getting wo se, no di)lo)ia o eye )ain: Ba s: *ea ing ;e y )oo ?ilate ally: 1ym)anic mem? ane landma Cs well ;isuali3ed: Nose: No discha ge, no o?st uction, se)tum not de;iated: >outh: <om)lete set o5 u))e and lowe dentu es: Pha yn9 not in=ected, no e9udates: Wea s 5ull set o5 dentu es 5o mo e than # yea s, wo Cs well: 8;ula mo;es u) in midline: No mal gag e5le9: No histo y o5 tonsillitis o tonsillectomy 1

TMC Operating Room

Prof. Acena

NecC: =ugula ;enous ) essu e -cm, thy oid not )al)a?le: No masses: Nodes: No adeno)athy 3. Chest: B easts: at o)hic and symmet ic, nontende , no masses o discha ges: Lungs: ?i?asila ales: No dullness to )e cussion: 4ia)h agm mo;es well with es)i ation: No honchi, whee3es o u?s: No histo y o5 )leu isy, cough, whee3ing, asthma, hemo)tysis, )ulmona y em?oli, )neumonia, 1B o 1B e9)osu e ": Heart: P>7 at the ,th 7<S, 1 cm late al to ><D: No hea;es o th ills: 2egula hythm with occasional e9t a ?eat: No mal S1, S% na owly s)lit$ )ositi;e S" gallo): A g ade 77/E7 systolic e=ection mu mu is hea d at the le5t u))e ste nal ?o de without adiation: Pulses a e nota?le 5o sha ) ca otid u)st oCes: #: Pulses: <a otid ? achial adial 5emo al 4P P1 2 %F %F %F %F 1F + D %F %F %F %F 1F + ,: Spine: mild Cy)hosis, mo?ile, nontende , no costo;e te? al tende ness 7: Abdomen: so5t, 5lat, ?owel sounds ) esent, no ? uits: Nontende to )al)ation: Di;e edge, s)leen, Cidney not 5elt: No masses: Di;e s)an 1+cm ?y )e cussion: -. E tremities: sCin wa m and smooth e9ce)t 5o ch onic ;enous stasis changes in ?oth legs: 1F edema to the Cnees, non&)itting and ;e y tende to )al)ation: No clu??ing no cyanosis: A: Neurologi!al: AwaCe, ale t and 5ully o iented: < anial ne ;es 777&G77 intact e9ce)t 5o dec eased hea ing: >oto : St ength not tested, )atient mo;es all e9t emities: Senso y: G ossly no mal to touch and )in ) icC: <e e?ella : no t emo no dysmet ia: 2e5le9es symmet ical 1F th ough out, no Ba?insCi sign: "#. Neuromus!ular: *as mode ate isC 5o osteoa th itis o5 ?oth Cnees last .anua y %+1% a5te a ?one scan du ing e9ecuti;e checC&u):1he e is no histo y o5 sei3u es, st oCe, synco)e, memo y changes 11: $e!tal: P ominent e9te nal hemo hoids: No masses 5elt: Stool ? own, negati;e 5o ?lood %.&:: 2egula ly de5ecates once a day: 3 days ) io to admission, e9)e ienced consti)ation and mild gast ic )ain, tole a?le: 1%:%': 2e)o ts dysu ia 3 days ) io to hos)itali3ation, with minimal to no mal amount: No 5e;e , no hematu ia: No histo y o5 se9ually t ansmitted disease: No mal ) ostate: 13: Emotional: 4enies histo y o5 de) ession, an9iety: 1": Hematologi!al: Se;e al months ?e5o e this admission he was noted to ?e mildly anemic 2B<H 3:1 miilion cells/m3 $ *g?H A:3 gm/dl, hence gi;en i on su))lement 1#: $heumati!: no histo y o5 gout, heumatic a th itis, o lu)us: 1,: Endo!rine: Cnown dia?etic 5o 1+ yea s$ No thy oid disease: 17: (ermatologi!al: no new ashes o ) uitis: %

TMC Operating Room

Prof. Acena

Personal His or! 1: AGB is a widow and li;es with his younge son: %: (ccu)ation: *e used to wo C a? oad as an account e9ecuti;e 5o 1# yea s and then sta ted his own ?usiness whe e he wo Ced as a <(( in thei ga ment 5acto since #1 yea s old: Now eti ed, ?ut still su)e ;ises the ?usiness occasionaly: 3: *a?its: <iga ette smoCe when he was in college until a ound ,+ yea s old o5 a?out 3&# sticCs )e day: (ccasional d inCe : 4oes not 5ollow any s)ecial diet: ": Bo n in 1aytay 2i3al: *ad se;e al out o5 the count y ;isits, latest was in .uly o5 %+11: #: P esent en;i onment: li;es in a %&sto ey single detached house, in an e9clusi;e ;illage: *is oom is in the 5i st 5loo : With his son and two house hel)e s: ,: 0inancial: 2ecei;es social secu ity )ension, (S<A allowances and ) i;ileges, and ?usiness income: 7: Psychosocial: 1he )atient is gene ally an ale t and acti;e man des)ite his dia?etes mellitus and hy)e tension: *e unde stands that he is ha;ing a Ihea t attacCJ at the ) esent time and a))ea s to ?e an9ious: -: *e egula ly do mo ning walCs a ound thei ;illage 5o a?out 3+ minutes: *e sto))ed 3 days ago due to chest )ain: *e also )lays with his g andchild en as )ast time: A: *e is an acti;e mem?e o5 the chu ch and does e9t a chu ch wo Cs e;e y Sunday:

TMC Operating Room

Prof. Acena

C"rren Bloo# Res"l :

Bloo# C$e%is r! 0BS B8N <2BA P*(S <a Na M <l <*(D <PM 1 iglyce ide 8 ic Acid SG(1 SGP1 0e 1P ADB GD(B AD1 ADMP AS1 GG1 1B7D Res"l 1+% A +:%:A:% 1"3 ":1 1+3 1-A "-+ A1 7:+ %#3 1%A %# 3:A 3:" %, 1## ## 17 +:# Nor%al Ran&e 7+&11+ mg/dl 7&1- mg/dl +:, K 1:% mg/dl %:7&":# mg/dl -:-&1+:+ 1+1&111 mB//D 3:# K #:+ mB//D A-&1+, mB//D 1%+&%%+ mg/dl >: 3-&17" 8/D$ 0:A,&1"+ 8/D >: "+&1,+ mg/dl$ 0: 3#&13# mg/dl >: 3:#&7:% mg/dl$ 0: %:,&,:+ mg/dl +&"1 8/D %+&7+ 8/D >: 7#&17# g/dl$ 0: ,#&1,# g/dl ,&- g/dl 3:-&#:+ g/dl %:3&3:# g/dl 1&"+ 8/D %+&7+ 8/D >: ,&%, 8/D $ 0: "&1- 8/D +:%&1:+ mg/dl Bloo# C$e%is r! *4D D4D Co%'le e Bloo# Co"n *g? *ct 2B< >onocytes Dym)hocytes Baso)hils Bosino)hils Neut o)hils Platelets WB< Urinal!sis )* S)eci5ic g a;ity P otein Glucose 2B< WB< < ystals Bacte ia Res"l 7% 1"+ Res"l 1%:+ 3":"% +:-A %:3 +:+# +:+1 ":% %11%:" Res"l ,:# 1:++1&% Negati; e + many None F Nor%al Ran&e >: 3+&7+ g/dl$ 0: 3+&-# g/dl -+&1"+ mg/dl Nor%al Ran&e 1%:, &17:7 g/dl 37:# K #1:+ L ":1"& #:-+ 9 1+3 / uD +:1 &1:+ 9 1+3 / uD +:7 K ":# 9 1+3 / uD +:+ &+:% 9 1+3 / uD +:+ K +:" 9 1+3 / uD 1:- K 7:- 9 1+3 / uD 1"+& "1# 9 1+3 / uD ":+&1+:# 9 1+3 / uD Nor%al Ran&e ":, K -:+ 1:++# K 1:+3+ None to - mg/ 1++ ml Negati;e +&%:+ +&" )e low&)owe 5ield None None

"

TMC Operating Room

Prof. Acena

O $er Dia&nos i(s: 1: ABG: )* 7:",$ )<(% & 3" $ P(%& -"$ (%$ Sat A-L ! oom ai ' %: BMG: NS2 A,, S1 ele;ations 7, AED, E"&E,$ a e uni5ocal EP<s 3: <G2 )o ta?le AP, ) o?a?le ca diomegaly, mild PE< Ini ial #ia&nosis "'on a#%ission: 1: Acute antelo ate al myoca dioal in5a ction, com)licated ?y mild le5t ;ent icula dys5unction: Patient has ecei;ed th om?olysis the a)y: %: *y)e tension 3: 4ysu ia & 3F ?acte ia in u ine with )yu ia ": 4> 1y)e 77 & cont olled S"r&i(al Plan: 0o )ossi?le <o ona y A te y By)ass G a5t a5te "- hou s o5 o?se ;ation A##i ional %e#i(a ions #"rin& $is a#%ission: 1: As)i in #: Dinagli)tin %: <lo)idog el ,: Eidagli)tin F >et5o min 3: Bno9a)a in 7: Dosa tan ": >eto) olol *<D -: Neu o?ion&B and <ent um

TMC Operating Room

Prof. Acena

GUIDE )UESTIONS: 1: 0ollowing the 5o mat gi;en to you, maCe a w itten case ) esentation: NNN No need to include the No mal Physical Assessment , 5ocus on a?no mal 5indings with analysis %: Also, answe the 5ollowing /uestions: a: What is the anatomy in;ol;ed in this illnessO ?: *ow a e the no mal 5unctioning o5 these anatomical )a ts a55ectedO c: What a e the a?no mal ?lood tests esultsO d: What a e the im)lications in ha;ing these a?no mal ?lood and diagnostic esults in te ms o5 )atients ci culato y 5unctioningO e: *ow can you e9)lain the changes in the clients ;ital signsO 5: >aCe a d ug study o5 all the medications taCen ?y the )atient, taCe note o5 its e55ect on the clients ci culato y 5unction: g: What will you ecommend to othe s to ) e;ent 5 om ha;ing the same illnessO 3: Watch how B<G is taCen: <hecC ;ia 6outu?e: K 2ecommended: a: I*ow to taCe B<GJ ?y hi atamCeen1 ?: I2eco ding a 1%&Dead B<G&1omo ows <liniciansJ ?y 2G8<>edia ": 4iscuss the )e i&o)e ati;e nu sing ca e 5o )atients 5o <ABG a: P e&o)e ati;e K what to e9)ect, la?o ato ies needed, assessment to ?e done, ) e)a ation and nu sing ca e ?e5o e o)e ation ?: 7nt a&o)e ati;e K site o5 <ABG, ) ocedu e in;ol;ed, inst uments needed c: Post&o)e ati;e K ca e o5 o)e ati;e site, assessment o5 com)lications o5 <ABG, )ost& o)e ati;e client education #: Watch how <ABG and angio)lasty is ?eing done: Watch it ;ia 6outu?e: 2ecommeded: a:I<o ona y A te y By)ass G a5t !<ABG' Su ge yJ ?y BducationNetwo C1E ?: IBalloon Angio)lasty <o ona y Angoi)lasty *ea t Su ge y P e()J ?y P e():com Eideo Patient Bducation ,: 4iscuss the mechanism and ) ocess o5 <ABG: a: P ocedu e ?: Nu sing ca e ?e5o e, du ing and a5te <ABG c: <lient education d: <om)a e <ABG 5 om an Angio)lasty