Running Head: CASE PRESENTATION
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Krystal Morris
NU 607 Adult Practicum II
Case Presentation
April 5, 2012
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CASE PRESENTATION
Patient Demographics and Pertinent Past Medical History
This patient is a 47 year old Caucasian male who presented to the Emergency Department
with a chief complaint of “going through a really bad alcohol withdraw lately.” Three days prior
to coming to the hospital, patient began binge drinking up to 2L of Vodka per day, his last drink
one day ago. Patient reports binge drinking until he can’t remember anything before blacking
out. Patients wife came home and found him unresponsive the day before, called his primary
care provider, and followed those recommendations. He became more alert, however other
symptoms progressed including: sweating, palpitations, nausea, dry heaves with some vomiting,
at least one fall with abrasion on lip, and urinary frequency. No food or fluid intake for several
days. Denies fever, chest pain, chest pressure, no vommitting frank blood or coffee ground
emesis. Regular bowel movements, no frank blood in stools, no black or tarry stools. Patient has
been on Librium on an as needed basis for the last 20 years, however is unable to obtain refills
from his primary care provider due to noncompliance.
Two weeks prior, this patient was seen at a low income clinic for urinary frequency and
difficulty initiating stream, although he has reported some overactive bladder symptoms his
whole life. The clinic performed a urinalysis which was negative for infection, and also
performed a prostate exam, and told patient that it is enlarged. Other past medical history of
alcohol abuse, depression and anxiety, and two previous suicide attempts. The patient reports
that he has a history of seizure activity with alcohol withdraw, but has not experienced any
symptoms in 20 years after starting Librium. The patient has been a binge drinker for 20+ years.
Past surgical history of a bilateral inguinal hernia repair. Patient denies a history of CVA, CAD,
DVT/PE or Diabetes.
Social History
His patient is married without any children. He reports binge drinking every 1-3 months,
binges usually lasting 2-3 days for the past 20 years. He usually took Librium for withdraw
symptoms. Patient reports going to several alcohol support groups weekly. He has been in an
inpatient rehabilitation for alcohol, and has sought treatment from many other places, per patient.
The patient has a 25 year pack smoking history. He denies any other substance abuse. Patient has
a history of 2 DUI charges. Pt is a full code blue.
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CASE PRESENTATION
The patient’s wife stepped out of room following initial interaction and reported
discrepancies in some of patient’s responses. She reports he binge drinks 2-3 night every week.
He did not regularly attend alcohol support groups.
Family History with Genogram
Family history includes that the patient’s father died of lung cancer after being a long
time smoker. The patient’s mother is still living with no medical problems. No further family
history reported. The patient denied a family history of Diabetes, CVA/, CAD, DVTs or PEs. See
Appendix A for genogram.
Review of Systems and Physical Exam
Review of Systems
Constitutional: Chills, sweats, fatigue, decreased activity. No fevers.
Eye: Dizziness and vertigo several days ago. Not present at this time.
Ear/Nose/Mouth/Throat: Negative
Respiratory: Negative.
Cardiovascular: Palpitations, no chest pain or heaviness associated with palpitations.
Gastrointestinal: Nausea, vomiting, loss of appetite. No food or drink other than alcohol for
several days.
Genitourinary: Urinary frequency, urinary hesitancy.
Hematology/Lymphatic: negative
Endocrine: negative
Musculoskeletal: Patient reports trips/falls frequently when balance is off from alcohol
consumption
Integumentary: Negative
Neurologic: Alert and oriented x4. Denies headache
Psychiatric: Anxiety, Depression, denies any current suicidal ideations.
Physical Exam
General: Alert and oriented, no acute distress.
Vital signs: Blood pressure: 150/77 (101), heart rate 105, O2 sats 96% on room air, 37.0 TMax
Eye: Pupils are equal, round, and reactive to light
HENT: Normocephalic
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CASE PRESENTATION
Neck: Supple
Respiratory: Lung are clear to auscultation bilaterally. Respirations are non-labored. Breath
sounds are equal. Symmetric chest was expansion.
Cardiovascular: Irregularly irregular rhythm. No murmur, 3+ pulses, equal in all extremities.
Capillary refill <3 seconds.
Gastrointestinal: Normal bowel sounds. RUQ tenderness to deep palpation
Musculoskeletal: Normal full range of motion. 5+ strength in all extremities.
Integumentary: Warm, dry.
Neurologic: Alert, oriented. Normal sensory. Cranial nerves II-XII are grossly intact.
Psychiatric: Cooperative, appropriate mood and affect, non-suicidal.
Laboratory and Diagnostic Tests
Lab tests ordered: CBC, CMP, PT/INR, Cardiac Markers, Hgb A1C, toxicology screen,
urinalysis and culture
EKG: Sinus tachycardia with trigeminal pattern PVCs.
Chest X Ray: Negative on wet read, awaiting final report
CBC &
Differential
WBC 17.8 H
RBC 5.01
Hgb: 15.8
Hct: 43.7%
MCV: 87.2
Platelets: 300
Neutrophils: 76.6%
H
Lymphocytes:
13.8% L
CMP
Na: 120 L
K 3.7
Cl: 79
Co2: 21
Glucose: 162H
BUN 23
Creatinine: 1.2
Ca: 10.1
Total Protein:
8.4H
Albumin: 5.1
Alk Phos: 64
AST: 32
ALT: 39
Total Bilirubin:
0.6
Lipase: 23
GFR: >60
Hgb A1C: 5.6%
with estimated
glucose of 114
PT/INR
Cardiac
Studies
CKMB: 5
Toxicology
Screen
PT: 12.50
Negative for:
sec
Ethanol
INR: 0.95 Myoglobin:
Barbituates
295H
Bezodiazepines
Cannaboid
Troponin: <.01 Cocaine
Methadone
CK: 483 H
Phencyclidine
Oxycodone
Acetaminophen
Amphetamines
Urinalysis
Clarity: Clear
Glucose: Negative
Bilirubin: Negative
Ketones: TRACE
Specific Gravity: 1.020
Blood: MODERATE
amount
PH: 6.0
Protein 100mg/dl H
Nitrates: Negative
WBCS: 12 to 50 H
RBC: 5 to 10
Bacterial FEW
Hyaline Casts: 50 to
100H
Mucous: Present
This UA was then sent
for culture
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CASE PRESENTATION
Differential Diagnosis
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Closed head injury
o Pt reports blacking out and has a history of falls. Newer abrasion on lip.
o CT to r/o head injury, Q2 hour neuro checks to monitor for mental status changes
Hypovolemia
o Frequent vomiting
o Obtain orthostatics to further assess. Start IVF if necessary
Illicit drug abuse
o Based of symptoms of sweating, palpitations
o UDS
o Obtain history from patient and wife
Bipolar Disorder
o Patient’s binge drinking could be a sign of mania follow by low periods when
patient is withdrawing
Pyelonephritis
o Urinary frequency, hesitancy
o Obtain UA. Has patient been having fevers? Flank pain? Blood in urine?
Librium Withdraw
o Patient usually takes medication for withdraw symptoms, hasn’t been able to
obtain a refill from his primary care physician due to compliance issues.
o Symptoms of withdrawal include sweating, palpitations, tremors
Final Diagnoses with plan of care
-This patient had numerous diagnoses for this inpatient admission. All of these diagnoses are
being addressed during hospitalization. Below is a rationale for each diagnosis along with a plan
for addressing each one. For the top 5 diagnoses, evidence based guidelines are summarized in
support of treatment interventions.
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Alcohol withdraw
o Pt reports binge drinking x3 days. Reporting withdraw symptoms such as chills,
diaphoresis, fatigue, insomnia, anorexia, & palpitations
o Plan of Care: CIWA (alcohol withdraw) protocol with thiamine, folic acid and
banana bag. Valium ordered PRN for seizures. Seizure precautions.
o Reference: Up to Date Alcohol Withdraw
o Plan of care is consistent with guidelines found for management of moderate and
severe alcohol withdraw syndrome. Management guidelines are to r/o other
diagnoses, then to control symptoms and provide supportive care. Symptomatic
support with Benzodiazepines is recommended, along with a quite protective
environment. Volume deficits were present in this patient, therefore isotonic IVF
is indicated. It is also recommended to give thiamine and folic acid which were
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CASE PRESENTATION
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ordered for this patient. Recommended that the patient is NPO during early
phases to prevent aspiration. According to the Up To Date reference, the care
prescribed for this patient is supported by evidence based practice.
Sepsis present on admission
o Pt SIRS criteria: WBC >12,000, Tachycardia >90
o Plan of Care: Monitor labs and vital signs. Bolus 0.9% Sodium Chloride
o Reference: Up to Date SIRS
o SIRS criteria states that 2 or more of the following must be present in order for +
criteria: Temperature >38.5 or <35, HR >90, RR >20 or PaCo2 <32, WBC
>12,000 or <4,000 or >10% immature band. According to these criteria, patient
met SIRS criteria. For the diagnosis of Sepsis, known source on infection must be
present. Patient has a UTI, known source of infection. These guidelines were used
to properly diagnosis sepsis.
UTI Present on Admission, culture pending
o See lab results for abnormal values from culture
o Plan of Care: Start IV Rocephin. Once culture is back, make sure organism is
susceptible to Rocephin. 1g IV Q24H.
o Reference: Up to Date UTI and Micromedex Rocephin
o Abnormalities on UA results indicate a UTI per literature. First line treatment for
uncomplicated UTI in men is Bactrim and Floroquines (Cipro, Levaquin).
According to Micromedex 2.0, Rocephin is an appropriate choice for an
uncomplicated UTI. Maximum daily dose is 2g IV. 1g is dosage that is
prescribed. Therefore, this antibiotic is an appropriate choice for this patient.
Hyponatremia
o Na: 120
o Plan of Care: Monitor Na on Labs. Start NS gtt at 125ml/hr. Monitor for a slow
rise in the serum Na. Monitor for MS changes that can be associated with
hyponatremia.
o Reference: Up to Date Hyponatremia
o Evidence Based Practice Guidelines for the management of hyponatremia
recommend several approaches for increasing Na. Fluid restriction to prevent a
further decrease in Na and IV NaCl in patients with true volume depletion. This
patient was experiencing volume depletion as seen by persistent vomiting and
orthostatic hypotension. Starting 0.9% NS will slowly raise serum sodium by
approximately 1meq/L for every liter of fluid infused. Continue to monitor other
electrolytes that can be associated with Na shifts.
Acute Renal failure
o BUN/Creatinine ratio is greater than 20/1 (23/1.2)
o Plan of Care: Monitor urine output and lab trends
o Reference: Up to Date: Acute Kidney Injury (Acute Renal Failure)
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CASE PRESENTATION
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o According to the literature, an increase in serum creatinine >0.5mg/dl above
baseline is considered Acute renal failure. Baseline creatinine was obtained 3
months prior, showing a creatinine of 0.7mg/dl. Creatinine today is 1.2. This is
>0.5 above baseline, therefore can be considered acute renal failure. Volume
depletion is the likely cause for the increase in creatinine. Therefore, volume
resuscitation and closely monitoring urine output is vital to this patient.
Hypochloremia
o Cl: 79
o Plan of Care: Monitor labs for increase in Cl, likely from vomiting. Plan to stop
vomiting through the use of antiemetics. IVF to help with the volume depletion.
Orthostatic Hypotension due to dehydration
o Baseline BP 150/77. Drop in BP from supine to sitting and then sitting to standing
o Plan of Care: Bolus 1L NS, start maintenance IVF, NS @ 125ml/hr
Intractable N/V
o Times several days
o Plan of care: PRN IV Antiemetics and NPO for now, okay to advance as tolerated
Sinus Tachycardia with Trigeminal pattern PVCs
o Per EKG and telemetry monitoring
o Plan of care: Telemetry and electrolyte monitoring. Cardiac enzymes Q6h x3
more draws. Troponin was <.01, myoglobin elevated
Urinary Frequency
o X2 weeks
o Plan of Care: Started on Rocephin IV which will help with urinary frequency
from UTI
Elevated glucose likely to stress response and infection
o Glucose 165 on Chemistry. A1C 5.4%
o Plan of Care: Monitor CBG Q6 hours.
History of Alcohol Abuse
o Several other hospital visits for alcohol abuse. History per patient
o Plan of Care: Psych nurse referral. Social work consult. Pt interested in
rehabilitation options
Depression
o Previous suicide attempts x2
o Plan of Care: Psych nurse referral. Pt reports uncontrolled depression with current
medication he is taking
History of Seizures with alcohol withdraw:
o Last seizure 20 years ago. Pt was on Libirum PRN
o Plan of Care: Seizure precautions and high fall risk. Withdraw protocol ordered
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CASE PRESENTATION
Emergency Department Care: ED course includes labs showing hyponatremia, hypochloremia,
acute renal failure, leukocytosis, elevated blood glucose. UA showed UTI. EKG obtained, pt in
ST with ventricular trigeminy. Cardiac markers obtained, zero hour negative. 0.9% NS bolus
x1L. Started banana bag. Chest x-ray wet read, nothing acute, official radiology read pending.
Patient Education: Discussed symptoms of alcohol withdraw with patient and wife, although
they were already familiar with symptoms due to previous episodes. Reviewed importance of all
the interventions for alcohol withdraw to help prevent seizure activity. Reviewed seizure
precautions and high fall risk. Explained the plan of care for hospitalization.
Referrals: Psych nurse referral/consult. Social work consult-patient interested in some type of
inpatient/outpatient alcohol rehabilitation. Cardiology consult for ST with trigeminal pattern of
PVCs.
Patient/Family Involvement: Patient was able to answer most interview questions independently,
yet wife stepped out of room and said that there were some inconsistencies with the patient’s
story. Support was provided to both the patient and his wife. Reviewed Plan of care and rationale
behind hospitalization and all interventions to be delivered.
Reflection of Care Provided
This patient was being admitted from the Emergency Department to Inpatient Telemetry. I spent
approximately 65+ minutes obtaining an H &P, performing a ROS, physical assessment, plan
and interventions. I feel that I obtained a thorough HPI and review of systems. The patient’s
thoughts were often disorganized, going off on different topics instead of answering the question
I could ask. I noticed improvements in redirecting the patient to make the interview process more
efficient. There was a point where the patient was talking about previous episodes with
rehabilitation. He said that he goes to several different local alcohol support groups. Looking
back, I wish that I had asked more about these groups, as the patient’s wife stepped out of the
room upon the completion of the interview and said that some of the patient’s story was
fabricated. I felt that I was able to independently formulate most of my diagnosis and develop
the plan of care, although I required some assistance with the wording and flow to my
documentation. Overall, this was a positive patient interaction. I felt like this experience helped
me grow when reflecting on the detail that went into documentation and developing a plan of
care.
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CASE PRESENTATION
References
Cefitriaxone Sodium. (2012). Dosing and Indications. Micromedex 2.0.
Hoffman, R.S., Weinhouse, G.L. (2011). Management of moderate and severe alcohol
Withdrawl syndromes. Up to Date 2012.
Hooton, T.M. (2011). Acute uncomplicated cystitis, pyelonephritis, and asymptomatic
Bacteriuria in men. Up to Date 2012.
Neviere, R. (2011). Sepsis and the systemic inflammatory response syndrome: definitions,
Epidemiology, and progrnosis. Up to Date 2012.
Palevsky, P.M. (2011). Definition of acute kidney injury (acute renal failure). Up to Date 2012.
Sterns, R.H. (2010). Overview of the treatment of hyponatremia. Up to Date 2012.
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CASE PRESENTATION
APPENDIX A:
Genogram
Paternal Grandfather:
Maternal Grandfather
Maternal
Grandmother:
Medical History:
UnknownUnknown
Maternal
Grandmother
Medical History:
Unknown
Medical History :
Unknown
Medical History :
Unknown
Father:
Mother:
Died of lung cancer.
Long time smoker. No
other known medical
problems.
Living. No medical
problems
Son (Patient)
47 years old. PHM alcohol abuse,.
Binge drinker every 1-3 months for
several days. Tobacco abuse.
Smoker, 25 pack year history.
Key:
Male
Female
Deceased
Medic
al
History
:
Unkno
wn