Case Study #5 Admitting History A 58-year-old Caucasian man is well known and liked by the staff at the Samaritan Shelter for the Homeless. The social workers at the shelter have spent a great deal of time and resources working with the man on a number of areas, including his alcohol addiction. Their records show that they have not seen him for about 6 months. When they last saw him, he was not drinking, had just secured a job as a janitor at a large department store, and was making enough money to eat and pay the rent on a small apartment. The staff members were saddened when he came to the shelter in search of some food and a bed. The man appeared tired, dirty, and depressed. He smelled of alcohol. He stated that he had quit his job about 3 months previously because his boss was “a jerk.” He also confirmed that he had been living on the streets again because of his inability to pay the rent. Although he chain-smoked as he talked to the staff members, he frequently complained about his “smoker’s cough.” Two days after he arrived at the shelter, the man began having episodes of coughing that were more severe than usual. On several occasions, the coughing spells lasted more than 2 hours. Hemoptysis often occurred during these periods. When the staff members at the shelter noted that the man had expectorated about a pint of fresh blood, they decided to transfer him to the local charity hospital. Although the man initially resisted, he finally agreed to go to the hospital. Physical Examination In the emergency room the man appeared anxious, chronically and acutely malnourished, weak, and in obvious respiratory distress. His nail beds were cyanotic, and his fingers were yellow from nicotine stains. The patient stated that he had smoked approximately 30 cigarettes a day for 35 years. He had a frequent, strong cough, producing moderate amounts of yellow sputum mixed with small amounts of fresh blood. He stated that his cough has been getting worse, and he thought that he probably had a “cold.” He also indicated that he could not seem to get his breath. The patient denied having any respiratory problems before this admission. However, he also stated that coughing up blood was “no big deal” because he had done it a couple of times before. Although the patient denied having used alcohol for months, the staff members from the shelter documented the smell of alcohol at the time of his admission at the shelter. The patient obviously had fallen in the recent past. He had several large bruises on his forehead, on his right shoulder and arm, and over his right anterior axillary chest region, between the sixth and ninth ribs. The patient’s vital signs were as follows: blood pressure 170/95, heart rate 110 bpm, respiratory rate 26/min, and oral temperature 38.3° C (101° F). Although palpation of the chest was negative, dull percussion notes and increased tactile and vocal fremitus were noted over the lung bases. Bronchial breath sounds were heard over the right and left lung bases. Crackles and rhonchi were noted over the right upper lobe. A pleural friction rub also was auscultated over the right lower lobe, between the fifth and sixth ribs in the anterior axillary line. A chest X-ray revealed an increased opacity consistent with pneumonia and atelectasis in the left lower lobe and right middle and upper lobes. A 5-cm cavity was easily visible in the left upper lobe (Figure 4-1). The patient had a hemoglobin level of 17 g/dl and a white blood cell (WBC) count of 14,000/mm3. The patient’s arterial blood gas values (ABGs) on room air were as follows: pH 7.53, PaCO2 51 mm Hg, HCO3– 41 mmol/L, and PaO2 50 mm Hg. His Mosby items and derived items © 2006 by Mosby, Inc. Case Study 2 carboxyhemoglobin level was 8.5%, and his hemoglobin oxygen saturation measured by pulse oximetry (SpO2) was 88%. Figure 4-1 Chest X-ray of a 58-year-old man with tuberculosis. 1. What disease process should the team suspect that he has? 2. What evidence supports it? 3. Are there any other signs or symptoms we could ask for? 4. What is the interpretation of the current blood gas? Why? 5. What tests can be administered at this time? 6. What are some immediate actions that he RCP could take? 7. What are some recommendations that the RCP could make? 8. What kind of isolation procedures should be started? 4 Days After Admission In reviewing the patient’s chart, the respiratory care practitioner noted that the patient had a positive tuberculin reaction. An acid-fast stain and sputum culture had been obtained. Also noted was the fact that the patient had undergone fiberoptic bronchoscopy. During this procedure, both old blood and fresh blood were found throughout the tracheobronchial tree. Secretions obtained from the large airways tested negative for malignant cells. A complete pulmonary function test (PFT) indicated a moderate-to-severe restrictive disorder. The morning chest X-ray showed an improvement in the aeration of the lung bases, as compared with the admission radiograph. The patient’s cyanosis and respiratory distress appeared better. His cough was still frequent and productive. The amount of sputum, however, was not as great as that on admission. Although the sputum was opaque, it was no longer yellow, and no blood could be seen. The patient stated that his cough was a lot better. Mosby items and derived items © 2006 by Mosby, Inc. Case Study 3 His vital signs were as follows: blood pressure 143/90, heart rate 92 bpm, respiratory rate 18/min, and oral temperature 37.4° C (99.3° F). Dull percussion notes and bronchial breath sounds were noted over the lung bases. Rhonchi still could be heard over the right middle lobe, although they were not so pronounced as on admission. The pleural friction rub no longer was present. The patient’s ABGs were as follows: pH 7.48, PaCO2 60 mm Hg, HCO3– 42 mmol/L, and PaO2 61 mm Hg. His SpO2 was 91%. Acid-fast organisms were seen on direct smear of the bronchoscopically obtained secretions. 1. Is the pt in respiratory distress? 2. What evidence supports it? 3. What is the interpretation of the current blood gas? Why? 4. What are some immediate actions that he RCP could take? 5. What are treatment recommendations that the RCP could make? 6. If the patient’s condition, worsens what disease process could result? 7 Days After Admission As part of the discharge team on this day, the respiratory care practitioner reviewed the patient’s chart and noted that his morning chest X-ray had improved significantly. The parenchymal densities present in the lung bases on admission were much improved. The large cavity in the upper left lung lobe, however, was still clearly visible. Arrangements had been made with the staff at the Samaritan Shelter to dispense the prescribed drugs and monitor the patient’s compliance in taking them. On observation, the patient still appeared moderately pale and cyanotic, but he no longer appeared to be in respiratory distress. In addition, he no longer demonstrated a spontaneous, uncontrolled cough. The patient stated that he was ready to run a marathon. When asked to cough, the patient generated a strong, nonproductive cough. His vital signs were as follows: blood pressure 135/85, heart rate 80 bpm, respiratory rate 10/min, and oral temperature 37° C (98.6° F). Palpation and percussion were essentially negative. Normal vesicular breath sounds were audible over the lower lung fields. On a 1 L/min oxygen nasal cannula, the patient’s ABGs were as follows: pH 7.42, PaCO2 72 mm Hg, HCO3– 45 mmol/L, and PaO2 78 mm Hg. His SpO2 was 94%. Three successive sputum smears over the last 4 days were acid-fast bacilli (AFB) negative. 1. Is the pt in respiratory distress? 2. What evidence supports it? 3. What is the interpretation of the current blood gas? Why? 4. What are some immediate actions that he RCP could take? 5. What are some recommendations that the RCP could make? 6. What first line drugs could be ordered for this patient? 7. What ensures that this patient will comply with his therapy? Mosby items and derived items © 2006 by Mosby, Inc.