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MSU - GREAT FALLS
RESPIRATORY CARE PROGRAM
CASE STUDY
Student:
Hospital:
Patient (Initials):
Age:
Diagnosis: Respiratory failure and mental
Sex:
Admit Date: 1/12
status change, Sepsis, Acute Renal Failure,
Hypothermia, Narcotic Overdose
HISTORY & ADMIT PHYSICAL EVALUATION (In Your own words):
History of Present Illness:
? is a 31 year old female who was brought to Benefis after being found unresponsive in her trailer by a friend. Prior to
her friend finding her, it is stated that the patient was walking around outside without proper clothing on for the
temperature of around 0 F. Upon the arrival of EMS, the patient became combative and agitated. She would only
follow some commands and answer a few questions while complaining that she can’t breathe. She became more
confused and her responsiveness deteriorated yet again. The only relevant history that EMS was able to obtain during
transport was that she has had some generalized weakness and difficulty walking at times and that she has a history of
narcotic and marijuana use. She was started on oxygen by a non-rebreather mask, and 2 IV’s had been started on saline.
Along with her agitation, she was disoriented and appeared to be intoxicated and unkempt. At this point, she was
tachycardic, tachypneic and hypothermic. Both pupils were not reactive to light and her eyes open spontaneously. EMS
also noted dry mucous membranes.
Upon arrival to the emergency department, her responsiveness and ability to maintain her own airway became
questionable so the choice to intubate was made. She was sedated with propofol for intubation. An 8.0 ET tube was
used and secured at 24 cm at the lip once confirmed visually along with CO2 detection device, breath sounds equal and
bilateral as well as a chest x-ray and improving oxygen saturations. Chest x-ray showed the ET tube ending just above
the carina. An orogastric tube ends in the proximal stomach. The heart size is normal with mild opacifications in the
perihilar regions of the lungs bilaterally. No pneumothorax or pleural effusion was noted. She was placed on the LTV
transport ventilator in assist control mode with the following settings; a rate of 14, tidal volume of 500, PEEP of 5 and
50% FiO2. An EKG was done showing sinus tachycardia with a normal rhythm along with normal P waves, QRS
complex, and T waves. She had received 4 liters of saline and her temperature was now 95 F. Lab studies in the
emergency department were an initial chest x-ray showing some perihilar infiltrates that may be indicative of possible
aspiration. Her WBC count was 38.1, Hemoglobin 14.8, platelet count 357. A chemistry panel showed a sodium of
146, potassium of 4.3, carbon dioxide 15, chloride 113, creatinine 4.8, BUN 41, and glucose 144. She had an AST of
100 and an ALT of74. A blood gas was also drawn with a pH of 7.17, PaCO2 of 32.8, a PaO2 of 130 and a HCO3 of
11.6. A toxicology screen was done revealing positive for marijuana and amphetamine.
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She presents to the ICU with a pulse of 109, respiratory rate of 12, temperature of 95.2 and a blood pressure of 166/98,
and saturation of 100%. Her pupils are now reactive to light. She remains intermittently agitated as well as calm on the
ventilator. The transport ventilator settings are matched on the 840 except her rate has decreased to 12. Peak pressures
were 22, static pressure was 20, static compliance was 38, mean airway pressure was 5.7. Total minute ventilation was
6.29, rate was 12 and her tidal volume was 524. She was on a non-heated circuit with an HME. Her mucous
membranes are moist. Her toes are cyanotic and cool to the touch with pedal pulses present. She is able to move all
extremities when she is agitated.
On 1/17/12 vent settings were changed to spontaneous mode with a pressure support of 15 and a PEEP of 5. Peak
pressures were 20, mean airway pressure was 8.4 and total minute ventilation was 7.1 with a respiratory rate of 20.
Spontaneous tidal volumes were 374. FiO2 has been weaned to 40% as well. She had a saturation of 99 % with a heart
rate of 124.
At this point, methamphetamine psychosis will be the principal concern. Hypothermia also playing a major role in her
case, but could be modifying a typical methamphetamine psychosis. She also is experiencing leukocytosis and possible
sepsis. She has a metabolic acidosis and acute renal failure. Pulmonary infiltrates noted on the x-ray indicate a possible
aspiration pneumonitis but could possibly be pulmonary edema, acute lung injury or the early stages of ARDS. There is
evidence to support IV drug abuse as there is skin popping on her right foot, which is ischemic. Pregnancy is also a
possibility at this point. She will remain full code at this time.
Past Medical History: Drug abuse and remarkable for migraine headaches.
Surgeries / dates: None available
Social & Family History: She currently lives in a trailer. Unclear if she lives there by herself at this time. She does
have a significant other who is in New Mexico for a funeral.
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PRESENTING PROBLEM LIST: (taken from Hx of PI)
Combative and agitated.
Dyspnea
Confusion
Altered mental status
unresponsive
History of and current positive narcotic and marijuana use
IV drug abuse
Unreactive pupils
Dry mucous membranes
Mild opacifications in the perihilar regions of the lungs bilaterally
Possible aspiration
Leukocytosis
Hyperchloremia
Elevated AST
Elevated ALT
Elevated Creatinine
Elevated BUN
Hyperglycemia
Hypocapnia
Tachycardia
Tachypnea
Hypertension
Hypothermia
Cyanotic toes
Metabolic acidosis
Hypernatremia
Generalized weakness & difficulty walking
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DIFFERENTIAL DIAGNOSIS: (Based on presenting problems list, what differential diagnosis could have been made or ruled out)
Alcohol Toxicity-Serum glucose level, CBC, serum isopropanol, serum methanol, BUN and Creatinine baseline
Barbiturate Toxicity-CBC, electrolytes, BUN, creatinine, glucose, arterial blood gas
Benzodiazepine Toxicity- Arterial blood gas, serum electrolytes, glucose, BUN, creatine clearance, ETOH and
acetaminophen concentration
Opioid Toxicity- CBC, metabolic pane, creatine kinase, arterial blood gas and urinalysis
Hypernatremia- Serum electrolytes, glucose level, urea, creatinine, 24 hour urine volume
ARDS- Arterial Blood Gas, plasma B-type natriuretic peptide, echocardiogram, hematology, renal and hepatic panels,
Chest x-ray
Aspiration Pneumonia- Arterial blood gas and mixed venous gas, metabolic panel, CBC, sputum gram stain and
culture, chest x-ray
Neurogenic Pulmonary Edema- Cardiac enzyme elevation and elevated natriuretic peptides. No specific laboratory
study confirms neurogenic pulmonary edema.
Problems the Patient Could Have (based on Admitting Diagnosis)
1. Respiratory Failure
Diaphoresis
Cardiac Arrhythmia
Coma
Jugular venous distention
2. Sepsis
Chills
Fever
Hyperventilation
Lightheadedness due to low blood pressure
Shaking
Skin rash
Warm skin
Signs and symptoms related to the organ/s involved
3. Acute Renal Failure
Bloody stools
Breath odor
Decreased appetite
Decreased sensation
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Flank pain
Hand tremor
Nosebleeds
Persistent hiccups
Seizures
Slow, sluggish movements
Swelling of the ankle, foot and leg
Excessive urination at night
4. Hypothermia
Shivering
Stumbling, lack of coordination
Lack of concern for her condition
Weak pulse
Slow, shallow breathing
5. Narcotic Overdose (Methamphetamine)
Arrhythmia
Chest pain
Dizziness
Nausea
Diarrhea
Stroke
Seizures
Muscle rigidity
Hyperthermia
Rhabdomyolysis
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PATIENT ASSESSMENT: (Must see & assess patient over a 3 DAY period of time): Your 1st day of
assessment should be a thorough PT Assessment; The subsequent 2 Assessments should be in SOAP
format.
Adult Patient Assessment
HOSPITAL DAY 3 & TIME: 1945
Age/sex 31 y/o Female Height 5ft 7in Weight 90.8 kg or 199.76 lbs IBW 61.6 kg or 135.5 lbs
Admitting Diagnosis: Respiratory failure and mental status change
Secondary Diagnosis: Sepsis, Acute Renal Failure, Hypothermia, Narcotic Overdose
Pulmonary Diagnosis:
Other Diagnosis:
Subjective Data: No subjective data is available at this time. She is currently sedated to prevent further
agitation.
Oxygen Therapy
Device: 840 ventilator FiO2: 50% Flow rate: 60 L/min
Aerosol & Humidity Therapy
Device: HME
Temp: N/A
Appropriate Rel Humid.: Given her
recent hypothermia, a heated wire circuit would be better
at this time
Hyperinflation Therapy
Device: +5 PEEP
Bronchial Hygiene
Technique: ET suctioning prn
Ventilator Settings
Mode Spontaneous
Rate ---Vol/Press ---PS 10
PEEP 5
FiO2 50%
I:E ----Flow 60 L/min
Waveform Descending ramp
SpO2: 100
Comment [BC1]: Please include what has taken
place, if anything significant, from the 17th, day 1,
which you described in HxPI, until now. What has
taken place over the last 2 days?
EtCO2: 38
Resp Medications: 6 puffs Albuterol Q4
Actual Values
RRtot
28
Vt
317
Min Vent 8.87
I:E---PIP
15
MAP
8.8
Static P & Compliance: --- /--Additional Settings:
N/A
Tube Size & Depth:
8.0 @ 24 cm
Graphics Interpretation: Presented adequate for the
patient with no signs of overshoot, no patient
discomfort or fighting the ventilator was noted. Peak
and static pressures were within normal ranges.
Additional Therapies/Procedures/Lines: Right side antecubital IV, right PICC line, orogastric tube, Foley
catheter, Aline?
Comment [BC2]: Spont mode with PS breaths
have a exponential decay waveform , the screen
shows the prescribed breath info including flow and
waveform bc if you push the manual insp button it
will provide that prescribed breath with those
settings, but those settings do not apply to the PS
spontaneous breaths.
Comment [BC3]: Not taken or relevant with
spontaneous ventilation.
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Physical Assessment
Interpretation of Physical Assessment
Initial Impression & General Appearance:
Sensorium: Oriented x 0
Cough: Suction
Sputum: Amt: Small Color: Cloudy
Consistency: Watery
Patient is sedated and on the 840 ventilator. No sensorium at
this time. Overall pink and warm with good capillary refill
except in toes where cyanosis is still noted.
In-line suctioning resulted in a small amount of cloudy
colored sputum with a water-like consistency. Normal
respiratory secretions.
Patient is hypotensive from sedative and narcotic overdose.
Respiratory rate is increased due to an increased need for
ventilation since blood pressure is low and mechanical
ventilation is implemented.
Vital Signs:
Pulse rate 100
BP
97/42
Resp. rate 28
Sat
100
Temp.
37.1
Neck: Supple and no noticeable scars, tracheal
deviation or JVD.
Toes are cyanotic due to hypothermia and potential frostbite.
Lesions on the extremities and abdomen are side effects from
methamphetamine use.
Extremities: Cyanotic toes with pedal pulses
present. Cool to touch. There is a 1cm ulcer of the
left great toe. There are linear and pitted lesions of
her right foot, legs and arms with no purulent
discharge seen.
Abdomen: Obese. Soft, nontender with no
organomegaly noted and rare bowel sounds. Linear,
pitted lesions present here without purulent
discharge.
Thorax: Linear, pitted lesions also present
without purulent discharge.
Breath Sounds: The upper lobes are clear
while the bases are clear but diminished
Thorax also presents with linear pitted lesions due to
methamphetamine side effects.
Breath sounds appear clear in the upper lobes while
diminished throughout all lobes.
throughout.
Complete Blood Count:
WBC
18.5
(3.2-9.7 k/ul) Bands (0-10%)
RBC
3.33
(4.5-6.0 M/ul)
Interpretation
Complete Blood Count:
Leukocytosis- The noted lesions across much of her
body may raise the WBC count as the body is trying to
keep infection from taking control. The toxins from the
amphetamine use may also cause an increase in WBC
count. Staphylococcus Aureus is present in suctioned
sputum.
Anemia- With this patient’s history, anemia could be
due to a variety of factors. A diet low in iron, folic acid
or vitamin B12 may cause this. Drug use may alter
hormone function, thereby impairing erythropoietin to
make red blood cells. Amphetamine use can increase
sexual drive, therefore pregnancy is a possibility and
may cause a temporary anemic state.
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Hgb
HCT
Platelets
10.7
31.7
226
Comment [BC4]: Related to the anemia
(14.5-17.9 g/dl)
(42.6-51%)
(146-360k/ul)
Comment [BC5]: Related to the RBC anemia
COAGS: N/A
PT
PTT
INR
D-Dimer
(11.4-14.5 sec)
(25-39 sec)
(0.9-1.2)
(0-0.49 ug/ml)
Hepatic:
Hepatic:
AST
53
(15-37 IU/L)
ALT
AP
Bili
63
72
0.3
(30-65 IU/L)
(50-136 IU/L)
(0.2-1.0 mg/dl)
Blood Chemistry:
AST Elevation- This is only slightly elevated which is
surprising given her history. Drug abuse could cause
this elevation to occur. Moderate elevations could be
indicative of Hepatitis B or C, although ALT and
bilirubin levels would be increased as well. This patient
is also obese which could potentially result in her
having a fatty liver. Medications such as acetaminophen
may increase this level as well.
Blood Chemistry:
Na+
147
(135-145 mEq/L)
ClK+
Ca++
Mg++
PO4
CO2
Glu:
111
3.8
7.6
2.1
2.03
29.0
124
(98-107 mEq/L)
(3.5-5.1 mEq/L)
(4.5-5.8 mEq/L)
(1.3-2.5 mEq/L)
(1.4-2.7 mEq/L)
(21-32 mEq/L)
(74-106)
Renal:
BUN
23
Cr
0.9
I/O's: 1/17/12 Intake total
as 5649, Ouptut was 1850
Comment [BC6]: Normalizing since admit
Hypernatremia, hyperchloremia, hypercalcemia and
hyperglycemia are all minimally out of normal values.
Drug use may alter the function and normal balance of
electrolytes in the body.
Renal:
(8-25 mg/dl)
(0.5-1.1 mg/dl)
I’s and O’s: Since 1/17/12, total retention is 5731.
Comment [BC7]: Now normalized since admit.
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mL resulting in a balance
of 3799.
1/18/12 Intake total was
3572, Output total was
1640 mL, resulting in a
balance of 1932.
Cardiac: N/A
CK-MB
Trop I
(< 4-6%)
(< 0.4)
Blood Gases:
pH
PaCO2
7.454
40.3
Blood Gases:
Compensated metabolic alkalosis.
Good oxygenation, pleth and oximetry.
pH is increased due to an increased amount of HCO3 in
the body.
HCO3
27.6
PaO2
101.0
Hb
11.7
HbO2
96.1
Abnormal Hb's:
Carboxyhemoglobin 1.5
Methemoglobin
0.5
Reduced Hemoglobin 1.9
A-a gradient
205.1
O2 cont
15.9
A-a Gradient is out of range. Diffusion defect, V/Q
mismatch or anemia. Most likely anemia in this case.
Oximetry/Pleth: 100%
with good pleth
Capnography: 38mmHg
Micro:
Sputum Culture
Staphylococcus Aureus,
Coagulase Positive
Gram Stain
Moderate neutrophils seen
with occasional squamous
epithelial cells. Moderate
gram positive cocci, few
gram positive rods and
occasional gram negative
rods
Other:
Capnography is correlating well with actual blood
values.
Micro:
Staphylococcus Aureus infection is present in the
sputum. Vancomycin and bacitracin have been started
as treatment. Probable cause of increased WBC count
along with other factors as listed above.
Comment [BC8]: Discuss a comparison of this
value to its admit value, what is to blame for the low
intial value?
Comment [BC9]: A-a is only telling of the
oxygen tension in the plasma and the lungs, PO2. It
does not relate to the rbc or hgb. It is simply a
measure of how well you are diffusing O2 across the
AC membrane. recall ficks law of diffusion
techniqies and procedures day one.
Comment [BC10]: How is the tracing?
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Hemodynamic Data & EKG’s
CVP (RA)
PAsys
PAdias
Rhythm Sinus Tachycardia
PAmean
PCWP
Rate 106
COL/m
CI
PVR
SVR
SvO2
Echo
Interpretation: Sinus tachycardia with a rate of 106
Pulmonary Function Results
Spirometry: SVC
FVC
Lung Volumes: TLC
FRC
FEV1
RV
FEV1/FVC
FEF 25-75
PEFR
Diffusion: DLCO
Interpretation: N/A
Imaging
X-rays: 1/17/12 The heart size and mediastinum are stable, unchanged since 1/16/12. Airspace opacitites are
bibasilar. An endotracheal tube ends approximately 2.1 cm superior to the carina. An orogastric tube ends in the
stomach. Possible bibasilar atelectasis or aspiration is noted.
1/17/12 PICC line from right arm with the tip overlying the SVC right atrial junction. PICC line in acceptable
position. The heart and mediastinal contours are normal. There is an endotracheal tube with the tip at the level
of the clavicles. An orogastric tube extends to the stomach. Patchy atelectasis in the lung base persists but may
be slightly improved.
1/18/12 The heart size and mediastinum are normal and unchanged since 1/17/12. Bilateral pleural effusions
with adjacent bibasilar airspace opacities have increased. Endotracheal tube is still in place, but the tip is
obscured by a radiopacity. An orogastric tube extends into the stomach and a right PICC line ends in the right
atrium.
1/19/12 Low lung volumes are noted with bilateral pleural effusions and dependent atelectasis is again noted.
No pneumothorax has developed and the cardiomediastinal silhouette remains stable.
1/20/12 Atelectasis and pleural effusions are again noted. Mild pulmonary edema is also present. No
pneumothorax is present and cardiac silhouette is stable in size.
Other:
Interpretation: 1/17/12 Bibasilar airspace opacities and possible atelectasis or aspiration noted. Adequate ET
tube and orogastric tube placement. Stable heart size and mediastinum.
1/17/12 PICC line placed in good position with improved atelectasis
1/18/12 Bilateral pleural effusions and bibasilar airspace opacities increased.
1/19/12 Low lung volumes with continued bilateral pleural effusions with atelectasis. No pneumothorax is
noted. Stable cardiomediastinal silhouette.
1/20/12 Atelectasis and pleural effusions are present and unchanged. Mild pulmonary edema is noted which is
due in part to fluid overload.
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Assessment & Plan
1. Mechanical Ventilation. CB is on the 840 ventilator due to respiratory failure from hypothermia and
narcotic overdose. She is in spontaneous mode at this time and is able to breathe on her own with a pressure
support of 10, PEEP of 5 and an FiO2 of 50%. Assessment and careful monitoring should be done to
determine how she will react to methamphetamine withdrawal before extubation is considered. She is
sedated and unresponsive to most commands and is still easily agitated. ABG values show the patient is
oxygenating well and maintaining normal CO2 levels. HCO3 is slightly elevated thereby increasing her pH.
Current settings and therapies are appropriate at this time. We will continue to assess and monitor.
Comment [BC11]: Atelectasis/effusions/Pulm
Edema – consider increasing PEEP.
Comment [BC12]: Change to heated wire.
2. Hypotension and tachypnea. The patient is currently hypotensive due to sedation and narcotic overdose.
This low blood pressure is increasing the patients need to oxygenate since the heart isn’t working as hard to
pump blood to the vasculature. This value isn’t too concerning at this time but if it continues as sedation and
ventilator assistance is weaned, a vasopressor may be considered to increase this value, given there are no
contraindications at that time.
3. Hypothermia. Toes are cyanotic and frostbitten from hypothermia. Continuous assessment of color return
should be performed. Topical antibiotics, aloe and anti-inflammatory medications should be considered as
treatment. If color does not return, surgery or amputation may be an alternative.
4. Skin Lesions. Patient has skin lesions across the thorax, abdomen and extremities. Methamphetamine may
cause hallucinations and psychotic episodes causing them to pick at their skin. High risk of infection is
present and antibiotic therapy should be continued at this time. Vancomycin, Bacitracin and Ampicillin are
current antibiotic therapies at this time.
5. Breath sounds. Breath sounds are clear and diminished in the upper lobes, while very diminished in the
bases. She is on a pressure support of 10 and PEEP of 5. Tidal volumes are running near 317 which is rather
small given her size. Increasing pressure support may help improve tidal volume and alveolar recruitment
and reduce her high respiratory rate.
6. Leukocytosis. The lesions across her body are a bacterial breeding ground for infection while in the ICU.
Lesions along with methamphetamine use may increase WBC count and cause leukocytosis.
Staphylococcus Aureus is also present in the sputum and may also be increasing her WBC count. Continued
antibiotic treatment and IV fluids are being given. Vasopressors should also be considered if IV fluids don’t
help improve blood pressure.
7. Anemia. A variety of factors may cause CB’s anemic state. Given her history of narcotic abuse, obesity and
general appearance, dietary reasons may be in partial blame for her anemia. Low iron, folic acid or vitamin
B12 may cause or contribute to her anemic state. Methamphetamine and other drugs can alter hormone
function and impair erythropoietin’s ability to make red blood cells. Sexual drive may also be increased
with methamphetamine use and therefore pregnancy is a possibility, which could also cause a temporary
anemic state. Since methamphetamine is the likely culprit, detoxification and rehabilitation will likely fix or
improve this issue.
8. Elevated AST. This slight elevation is surprising given her history. Drug abuse may cause this elevation. IV
drug use is high risk for contraction of hepatitis. However, given the mild elevation, acetaminophen is the
most probable cause of this elevation at this time. Continue to assess hepatic values for increased levels
potentially indicating hepatitis.
Comment [BC13]: This is true, but it is also
shown to increase ventilator dependence. Simv
would be a better choice. Also consider sedation
methiod on this patient in light of her Meth abuse.
P a g e | 12
9. Electrolyte abnormalities. Hypernatremia, hyperchloremia, hypercalcemia and hyperglycemia are all
present. Given her hypothermia and drug abuse these values are mildly abnormal and acceptable at this
time. Continue to closely monitor for any major changes.
10. Intake and Output. Since 1/17/12, total retention is 5731. Possible sepsis is being treated with IV fluids
and therefore fluid retention will continue to increase. Consult with physician about starting diuretic
treatments.
11. Staphylococcus Aureus infection. Vancomycin and bacitracin have been started as treatment. Probable
cause of increased WBC count along with other factors as listed above. Continue to watch WBC count
closely since patient may be septic, and could develop potential pneumonia as well. Continue antibiotic
medications.
12. Acute Renal failure. Patient experienced a drastic drop in blood flow and blood pressure from hypothermia
and sepsis. This is likely pre renal in origin and can be dealt with by improving blood pressure, fluid
administration, and antibiotic medications.
13. Sepsis. This patient has been tachycardic, tachypneic, has skin lesions an altered mental status and had
difficulty breathing. Methamphetamine use may weaken the immune system making her more susceptible to
infection. Broad spectrum antibiotics have been started like ampicillin. Continue to assess blood pressure
and consider giving vasopressors if an increase in blood pressure is not seen with fluid administration.
Obesity
Cyanotic feet – continue to monitor pulses and ultrasound if necessary.
SOAP ONE
SUBJECTIVE: Hospital day 4 @ 1730
CB is a 31 year old female who was admitted to Benefis on 1/16/12 for respiratory failure and mental status change.
Toxicology screen upon admit revealed amphetamines and marijuana abuse, which is the most likely the underlying
reason she is here. Patient is sedated on diprivan to prevent further agitation while being mechanically ventilated. She
does respond to some stimulus when doing oral care, very minimally however and with agitation.
OBJECTIVE:
The patient is 5ft 7in. tall and weighs 90.8 kg. Patient remains orally intubated on the 840 ventilator. From her
ventilator settings on 1/18/12, the following changes were made prior to my assessment. At 0435, the FiO2 was
decreased to 40%. Ventilator settings at the time of lab draws were spontaneous mode with a pressure support of 10
and PEEP of 5 and an FiO2 of 40%. At 1630 the pressure support was increased to 15 and the PEEP was increased to 7.
At 1730 her settings were as follows. Spontaneous mode with a pressure support of 15 and a PEEP of 7.0. FiO2 was
40% with a flow rate of 60. Actual values obtained were a rate of 21 breaths per minute, tidal volume 421, minute
ventilation 8.84. Peak pressures were 22 with a mean airway pressure of 11. She has an 8.0 tube taped at 24cm at the
lip.
Lab values were a WBC count of 15.2, RBC of 3.0, Hemoglobin of 9.8, Hematocrit 28.8 and a platelet count of 207.
AST was 34, ALT 56, Alkaline Phosphatase 73 and Bilirubin 0.4. Chemistry values were a sodium level of 147,
potassium 3.8, chloride 112, calcium 7.6, magnesium of 1.9, phosphorus 2.3, carbon dioxide 28.0 and a glucose of 128.
BUN has decreased to 15 and creatinine is 0.7.
Intake and output for 1/19/12 was an intake of 5984.5 with an output of 585 mL. This resulted in a balance of 5399.5 of
retained intake.
An arterial blood gas was drawn prior to her FiO2 decrease so she remains on 1/18/12 ventilator settings. The ABG
resulted in a pH of 7.414, PaCO2 43.7, PaO2 101.2, HCO3 27.3, a base excess of 2.4. End tidal CO2 monitor was 39.
P a g e | 13
Hemoglobin was 12.3, oxyhemoglobin 96.0, carboxyhemoglobin 1.5, methemoglobin 0.4 and reduced hemoglobin 2.1.
Oxygen content was 16.7.
Vitals at the time of my assessment at 1730 were a pulse of 93, blood pressure of 113/48, respiratory rate of 21
saturation 93% on 40% FiO2. Temperature was 37.0 C. Breath sounds had mild rhonchi throughout all lobes with
partial clearing after suctioning a large amount of thick, dark yellow sputum.
ASSESSMENT/PLAN
1. Mechanical Ventilation. Patient remains on the 840 ventilator. Pressure support has been increased to 15 and
PEEP increased to 7 in spontaneous mode while FiO2 decreased to 40%. Tidal volumes have improved. ABG
values prior to these vent changes reflected a well balanced pH, while CO2 and HCO3 are within normal limits.
These changes were most likely made to decrease the workload on the patient to breath and allow her to rest
while improving alveolar recruitment. Continue to assess
2. Leukocytosis. WBC count is still elevated but has decreased. Continue with current antibiotic medications,
sepsis protocol treatment and monitor lesions on her abdomen, thorax and extremities for signs of infection and
inflammation.
3. Anemia. Patient remains anemic due to factors as previously discussed. At this time, it may be good to consult
with the doctor about her decreasing RBC count. Consider giving packed cells if this number continues to
decline.
4. AST level. AST level is back within normal limits and under control at this time. Hepatic levels have improved
as well and are within normal ranges.
5. Electrolytes. The patient is still experiencing minimal electrolyte imbalances. Hypernatremia, hyperchloremia,
hypercalcemia, and hyperglycemia specifically. Continue to monitor any changes.
6. Intake and Output. 5399.5 mL of retained fluid intake has been retained for this day. Consult physician on
starting a diuretic. Since admittance 11,130.5 mL is the total amount of retained intake for this patient.
7. Vitals and breath sounds. Blood pressure has improved along with increased fluid administration. Patient is
slightly tachypneic, but this could be due to agitation and being mechanically ventilated. Breath sounds are mild
rhonchi throughout all lung fields with partial clearing after suctioning. Fluid overload is the most likely cause
of these lung sounds along with staphylococcus aureus infection.
8. Sputum and Staphylococcus Aureus infection. Thick, dark yellow sputum was suctioned which is indicative
of white blood cells in the sputum. Particularly neutrophils and eosinophils which may be found in cases of
chronic inflammation, allergic and infectious diseases. WBC count is dropping so the infection may be
receding.
9. Hypothermia. Hypothermia has been corrected. However her toes are frostbitten and we will need to continue
to monitor and treat with topical antibiotics, aloe and possibly anti-inflammatory medications. If cyanosis does
not improve fully, surgery or amputation may still be considered an alternative.
10. Skin lesions. Skin lesions are healing slowly and no discharge has been observed from these areas. Close
monitoring and continuing antibiotic treatment should be given to ensure further infection does not develop.
11. Sepsis. Patient is still on antibiotic medications and blood pressure has improved with fluid administration.
Vasopressors may not be needed if this trend continues. WBC count is decreasing which shows the infection is
starting to clear. Continue to treat with antibiotics and fluid administration at this time.
Comment [BC14]: Still recommend SIMV or
AC versus increasing PS alone.
P a g e | 14
12. Acute renal failure. This may be corrected as we treat sepsis. Since it is likely pre renal in origin from a
decreased blood flow and pressure to the kidneys and infection being present, fluid administration and antibiotic
medications will correct this along with sepsis most likely. Damage to the kidneys should be avoided and close
monitoring should be taken into account.
12.13.
Same comments as in previous A/P
SOAP TWO
SUBJECTIVE: hospital day 5 at 1515
CB is a 31 year old female who was admitted to Benefis on 1/16/12 for respiratory failure and mental status change.
She has tested positive on a toxicology screen for marijuana and amphetamine use. Patient is drowsy but appropriate to
questions and commands. She is able to move all extremities and makes a motion to ask if the tube can come out today.
Cooperative with treatment and oral care.
OBJECTIVE:
CB is 5 ft 7in tall and weighs 90.8 kg. Patient still remains orally intubated on the 840 ventilator with an 8.0 tube at 24
cm at the lip. Ventilator settings are: spontaneous mode with a pressure support of 15 and a PEEP of 7. FiO2 is 40%.
Total respiratory rate is 14 with a tidal volume of 516 resulting in a minute ventilation of 7.23. Her peak pressures are
22 with a mean airway pressure of 11. Her vitals were stable with a pulse of 84, saturation of 98, temperature of 37.4 C,
and a blood pressure of 115/92. Breath sounds upon auscultation were clear and diminished throughout all lung fields.
Suctioning revealed a small amount of white, cloudy colored sputum with a watery consistency.
Labs were drawn at 0455 today with an improving WBC count of 13.1. The patient still remains anemic with a RBC
count of 3.08, hemoglobin of 10.2, hematocrit of 29.4 and a platelet count of 224. AST has lowered to 32 and ALT is
56. Alkaline phosphatase has increased to 93. A chemistry panel was drawn with the electrolytes is back in balance
today. Sodium was 145, potassium 3.5, chloride 105, carbon dioxide 31.0, and glucose is still slightly elevated at 131.
Magnesium is 1.4, phosphorus 3.3 and calcium 8.0. BUN has lowered significantly to 13 and creatinine is 0.6.
Intake and output for 1/20/12 showed an intake of 4720 with an output of 4850. A balance of -130 was observed for
today. Furosemide has been started.
A morning blood gas was drawn at 0419 on the previously listed ventilator settings with a pH of 7.439, PaCO2 44.5,
PaO2 113.5, HCO3 29.5, Base excess 4.7, and the end tidal monitor was 45. Hemoglobin was 11.0, Oxyhemoglobin
was 96.5, methemoglobin 0.4, reduced hemoglobin 1.5, and oxygen content was 15.1.
ASSESSMENT/PLAN
1. Mechanical ventilation. Patient remains on the 840 ventilator with the same settings as 1/19/12. Respiratory
rate has decreased and tidal volumes have improved to 516. A morning blood gas on these settings show an
acceptable pH, PaCO2 is compensating for the high HCO3. ETCO2 monitor is working well with good
correlation to actual values and oxygenation is acceptable for these settings at this time.
2. Breath sounds. Breath sounds are clear and diminished throughout all lung fields while suctioning resulted in a
small amount of white, cloudy sputum with watery consistency. Most likely this is saline return from lavaging.
X-ray shows pleural effusions and probable pulmonary edema.
3. Intake and Output. An intake of 4720 was given today while 4850 mL was output. The patient has been
started on the diuretic furosemide to help remove excess fluid. Continue to closely assess her output in
comparison with input to make sure we are diuresing the patient correctly, while preventing kidney damage and
dehydration.
4. Sedation and heated wire circuit. Patient has been taken off of sedation at this time and is appropriate in
response to questions and commands. Lab values look adequate at this time. Changing to a heated wire circuit is
P a g e | 15
indicated and may help to loosen up secretions and remove some of the noted pulmonary edema and excess
fluid. This may also make the patient more comfortable if we can help remove secretions from the lungs now
that she is more alert.
5. Leukocytosis. WBC count is continually dropping and infection seems to be under control at this time. Once
WBC is back within normal limits, consult with pharmacy about discontinuing some antibiotic medications.
6. Anemia. Patient’s RBC count is slightly increased. Continue to assess for improvement. If adequate
improvement is not made, consider administration of packed red blood cells.
7. Electrolytes. Electrolytes have improved to within normal ranges except for a mildly increased glucose level.
Continue to closely monitor these levels as they are where they should be and this patient is slowly improving.
Hyperglycemia is not too concerning but should be watched. Hypercalcemia and hyperphosphatemia are also
noted to be slightly out of range and should be monitored. Electrolyte imbalance may occur when the patient is
being diuresed so these values are not too concerning at this time.
8. Hypothermia. Hypothermia has been corrected and toes are healing slowly. However her toes are frostbitten
and we will need to continue to monitor and treat with topical antibiotics, aloe and possibly anti-inflammatory
medications. Further down the road possibly hyperbaric oxygen. If cyanosis does not improve fully, surgery or
amputation may still be considered an alternative.
9. Skin lesions. Skin lesions are healing slowly and no discharge or signs of infection have been observed from
these areas. Close monitoring and continuing antibiotic treatment should be given to ensure further infection
does not develop.
10. Sepsis. Patient is still on antibiotic medications and blood pressure is still improving with fluid administration.
Vasopressors may not be needed if this trend continues. WBC count is continually decreasing. Continue to treat
with antibiotics and fluid administration at this time. Diuretic treatment has started and blood pressure should be
monitored closely.
11. Acute renal failure. Fluid output has started now that the patient is on diuretic treatment. Fluid administration
has helped to correct this issue but should be closely watched while the patient is on any form of diuretic
treatment.
P a g e | 16
Medication
Indication
Mechanism of Action
Complications
Acetaminophen
650 mg TID
Reduce pain and
fever
Pain relief and fever reducer
Drowsiness, nausea, dry mouth,
nervousness, dizziness
Albuterol Sulfate
Q4 inhaler
Increase airway
diameter and
decrease work of
breathing
Bronchodilator
Headache, nausea, nervousness,
increased heart rate, tremors
Aloe
Topical BID
Promote healing of
minor burns,
wounds and
frostbite
Wound healing accelerant
Burning, redness and itching
Ampicillin Sodium
200mls/hr IV Q6
Treatment of
bacterial infection
Fights bacteria in the body
Diarrhea that is watery or bloody,
agitation, seizure, decreased urination
Bacitracin
Topical
Treatment of
staphylococcal
infections
Antibiotic to fight infection
Lower back pain, painful urination,
nausea, vomiting
Fondaparinux
2.5mg daily
Prevents blood clots
Anticoagulant
Easy bruising, numbness, pale skin,
feeling light headed or short of breath,
unusual bleeding
Furosemide
80mg IV Q8
Treats fluid
retention
Loop diuretic (water pill)
Dizziness, lightheadedness, symptoms
of high blood sugar, fainting,
decreased urination
Lorazepam
2mg PO QID
Treats anxiety
Anti-anxiety
Confusion, depression, blurred vision,
insomnia
Moxifloxacin
250mls/hr IV
Treats different
types of bacterial
infections
Antibiotic to fight infection
Narcotic overdose
Reverses effects of other
narcotics
Relaxant, general
anesthetic, promotes
sleep
General anesthetic
Naloxone
IV as directed prn
Resp. rate <8
Propofol
IV prn
Vancomycin
200mls/hr IV Q12
Treats bacterial
infections
Antibiotic to fight infection
Seizure, confusion, easy bruising or
bleeding, mild diarrhea, blurred vision,
hallucinations, dark colored urine
Chest pain, wheezing, sweating, body
aches, confusion
Difficulty breathing, fast heartbeat,
seizure, uncontrollable muscle spasm,
palpitations
Lowered urine output, ringing in the
ears, fever, skin rash, fainting
P a g e | 17
PATHOPHYSIOLOGY (Research):
Respiratory Failure
Definition: Respiratory failure is a condition in which the levels of oxygen carried in the blood decrease to a
dangerously low level or when carbon dioxide levels become dangerously high. Acute hypercarbic respiratory failure is
defined as “the inability of the body to maintain a normal PaCO2” (1). It is also known as ventilatory pump failure.
This pump consists of the thoracic cage, the respiratory muscles and nerves and nerve centers that control our
ventilation.
Etiology/Pathology: Respiratory failure is noted by either low oxygen levels in the blood or high carbon dioxide levels
in the blood. With low oxygen levels, cyanosis may occur as well as shortness of breath. With the mismatched levels of
oxygen and carbon dioxide in the blood, the acidity in the blood may increase causing drowsiness or sleepiness.
Respiratory failure may be caused by an airway obstruction, such as COPD, asthma and cystic fibrosis. Poor breathing
due to obstructive sleep apnea, obesity, thyroid conditions or drug and alcohol intoxication may also cause failure.
Muscle weakness, abnormality of the chest wall and lung tissue are also causes. Hypercarbic respiratory failure is
usually exhibited by a pH of less than 7.30 and results from “decreased minute ventilation and/or increased physiologic
deadspace.”2 The elevation of CO2 causing the acidosis, results in an increase in cerebral blood flow as the cerebral
blood vessels dilate. In order to successfully treat respiratory failure, supplemental oxygen must be used, a patent and
clear airway must be maintained as well as continuously monitoring oxygenation and ventilatory status via an arterial
blood gas test and pulse oximetry. There are primarily three types of disorders which can cause respiratory pump
failure. These are neuromuscular disorders, central nervous system disorders, and disorders which increase the work of
breathing.
CB’s respiratory failure was due to multiple issues. Amphetamine overdose caused her to be in an altered mental state
P a g e | 18
most likely. This caused her to go outside without proper clothing on. Soon she became hypothermic on top of the
overdose. Once this occurred, somewhat of a negative feedback cycle was created causing her respiratory rate to
increase while trying to get more oxygen. This led to respiratory failure as she was unable to maintain her own airway
due to the drugs affects among other things.
Clinical manifestations: Symptoms may vary dependent on the cause. If the drive to breathe is in a normal state, then
the body may attempt to blow off carbon dioxide by taking deep, rapid breaths. Patients with acute respiratory distress
syndrome may experience severe shortness of breath over the course of several hours. Other manifestations include
diaphoresis, tachypnea, altered consciousness, tachycardia, respiratory arrest and eventually death.3
CB complained of shortness of breath between her moments of altered consciousness on the way to the hospital. She
became tachycardic and tachypneic as well which resulted in her being intubated and mechanically ventilated to
preserve her airway.
Mortality/prognosis: Respiratory failure can turn fatal if it does not resolve rapidly. Medical attention is required for
the best treatment. If resolution is not rapid, mechanical ventilation will most likely be necessary.
CB was fortunate enough to have the ambulance arrive and provide her medical attention. If they had not come she
would have died.
Treatment: Oxygen therapy is crucial in treatment of respiratory failure. In patients who live with higher carbon
dioxide levels, excessive amounts of oxygen may slow ventilation and therefore cause a larger increase in carbon
dioxide levels. The disorder causing the failure needs to be treated also. Antibiotics to fight infection may be prescribed
or bronchodilators to open up the airways. Rapid resolution is crucial to prevent mechanical intubation and ventilation
or death.
The treatment for CB was mechanical ventilation. She was unable to stay conscious enough to maintain her airway and
her combative nature and altered mental state was a concern to EMS. They had to sedate her for their own safety as
well as hers and therefore she could no longer breathe on her own, at which time mechanical ventilation was initiated.
Sepsis
Definition: Sepsis is defined as “an infection accompanied by an acute inflammatory reaction with systemic
manifestations associated with release into the bloodstream of numerous endogenous mediators of inflammation”4
Comment [BC15]: Well done. Good job putting
the pieces together. Perfect.
P a g e | 19
Etiology/Pathology: The inflammatory reaction may manifest itself with at least two of the following; Temperature
>38 C or <36 C, Heart rate greater than 90 bpm or a WBC count of >120,000 cells/uL.4
Severe sepsis is noted by signs of failure from at least one organ. Hypotension, respiratory failure from hypoxemia, or
renal failure may all be related to severe sepsis and may be a manifestation of cardiovascular failure.
The pathogenesis of septic shock is not fully understood. It is understood however that an inflammatory stimulus
triggers the production of the inflammatory mediators and therefore cause neutrophil-endothelial cell adhesion and
activate a clotting mechanism. This causes a release of other mediators which are opposed by anti-inflammatory
mediators and therefore create a negative feedback mechanism.
At this point the arteries may dilate and decrease peripheral artery resistance. Cardiac output may initially increase and
later decrease along with blood pressure. When cardiac output is increased, vasoactive mediators cause blood flow to
bypass the capillary exchange areas, resulting in poor capillary blood flow which results in microthrombi and shunting.
Ventilation and perfusion becomes inhibited and may result in one or more organ to fail.4
CB suffered from multiple factors which led to her sepsis. She was already immunocompromised given her
amphetamine abuse. When she became hypothermic, tachypneic and had a WBC count of 38,000, she was septic. She
also became hypertensive from her respiratory failure.
Clinical Manifestations: Fever, tachycardia and tachypnea are generally present with sepsis. Blood pressure may
remain normal for the time. With severe sepsis confusion and decreased alertness are seen along with falling blood
pressure. Extremities may become cool and pale along with peripheral cyanosis.4
As previously mentioned, CB was tachycardic and tachypneic upon admit. She was confused and had states of altered
consciousness along with cyanotic toes in part due to the hypothermia.
Treatment: Treatment of sepsis may vary depending upon the underlying cause. Antibiotic treatment will begin
immediately with broad spectrum antibiotics administered intravenously. Once the bacteria are identified, the antibiotic
regimen may be switched to better kill off the bacteria. Vasopressors may be given if the blood pressure remains low
after giving intravenous fluids. This will constrict blood vessels and help increase blood pressure. Low doses of
corticosteroids, insulin to maintain blood sugar levels, painkillers and sedatives may be given as treatment as well.5
Mechanical ventilation, oxygen, dialysis and surgery are also options and forms of treatment depending on the patient
condition.
P a g e | 20
Treatment for CB began with broad spectrum antibiotics and then specified antibiotics to deal with her staphylococcus
aureus and skin lesions. Fluids were administered to help increase blood pressure and sedatives were given to help
control her agitative state.
Mortality/Prognosis: Mortality of patients with sepsis is decreasing and now averages from 40%. The poor outcomes
are a result of early aggressive therapy. If severe lactic acidosis and decompensated metabolic acidosis forms along
with multi-organ failure, it is usually fatal and irreversible.4
At the time I treated CB, her lab work was overall pretty good with the exception of her WBC. Antibiotic treatments
were helping to bring this number down and help her body heal. Throughout my assessment I feel her overall general
condition was stable or improving and she will hopefully have a good prognosis if she continues on this path. Of course
once she is out of the hospital, it is up to her to find help, go to rehab and stay clean.
Acute Renal Failure
Definition: Acute renal failure is defined as “a rapid decrease in renal function over days to weeks, causing an
accumulation of nitrogenous products in the blood.” This most likely results from trauma, illness or surgery but may
also be caused by intrinsic renal disease.6
Etiology/Pathology: Causes of acute renal failure can be classified as pre renal, renal or post renal. Pre renal azotemia
is a result of inadequate renal perfusion. Volume depletion and cardiovascular disease are the primary causes. These
conditions usually do not cause permanent renal damage and are reversible. If hypoperfusion is severe enough to cause
tubular ischemia then damage will occur.6
Looking at renal causes, the involvement lies with renal disease or kidney damage. Most commonly prolonged renal
ischemia and nephrotoxins may cause this. Vascular and tubule damage may be caused ischemia from cellular debris or
protein or a crystalline deposition.
Postrenal azotemia may be due to a form of obstruction in the voiding and collecting parts of the urinary system.
Cellular debris, crystalline or protein material may block or obstruct the tubules and therefore blocks renal blood flow.
Initially the flow and pressure within the glomerular capillary may increase. Once the renal blood flow is reduced this
pressure and flow decreases since the afferent arteriolar resistance is no longer functioning. It may take up to one week
once the obstruction is removed before renovascular resistance returns to normal.6
CB’s condition was pre renal, meaning that the cause was before it reached the kidney. Her hypoperfusion due to low
blood pressure and sepsis played a role in causing her acute renal failure, but looking at her renal values, minimal
damage occurred.
P a g e | 21
Clinical Manifestations: Clinical manifestations may include bloody stools, easy bruising, mental status changes,
fatigue, flank pain, hypertension, nausea or vomiting, and decrease in urine output.7
Easy bruising, mental status changes, fatigue and decreased urine output are all manifestations that occurred in CB’s
case. However it is hard to determine what the underlying cause of these symptoms are when amphetamine use is
involved.
Treatment: The goal of treatment is to restore and protect kidney function while preventing fluid and waste from
building up in the body while the kidneys heal. Antibiotics may need to be taken to prevent or treat infection. Diuretics
may also be given to help the kidneys lose excess fluid. Dialysis as well as calcium and glucose or insulin may be given
as treatment as well.7 Treatment is dependent upon the underlying cause.
Fluid was retained in CB’s case to help improve her blood pressure and help treat sepsis. Once her blood pressure was
improved, diuretic treatments were started to help remove this excess fluid. Antibiotic medications were also started to
treat her infection.
Mortality/Prognosis: Acute renal failure can be a life-threatening issue and if not dealt with properly can have
dramatic consequences. If intensive and aggressive treatment is given to treat the underlying cause, then the kidneys
usually will start to work again within several weeks to months.7
CB’s acute renal failure was dealt with well and the underlying causes were treated. She was rewarmed from
hypothermia, she was started on antibiotics to control infection and IV fluids were administered to improve blood
pressure. She should have a positive prognosis at this point in the realm of acute renal failure.
Hypothermia
Definition: Hypothermia is classified as “a core body temperature less than 35 C. Symptoms may include shivering
and lethargy, to coma, confusion or death.8
Etiology/Pathology: Hypothermia results when the body heat loss exceeds body heat production.8 Most commonly it
occurs in cold weather but it may occur in warmer climates if someone is immobile on a cold surface or in water for a
long period of time. Alcohol and drug use are predisposing factors that may cause loss of consciousness or immobility.
Seizures or stroke may also be included in predisposing factors.
P a g e | 22
When looking at types of hypothermia, there are two classifications. Mild hypothermia requires a warm environment
while incorporating passive rewarming such as blankets. Sever hypothermia requires active rewarming of the actual
body surface with warming systems or radiant sources.
Hypothermia slows the body’s physiologic functions along with cardiovascular and respiratory systems, mental acuity
and nerve conduction. Our body’s ability to maintain thermoregulation ceases below roughly 30 C and the body must
then depend on other heat sources to match our heat loss with heat production or absorption.8
No clinical values were given regarding her temperature when she was found that was accurate to my knowledge.
However, emergency room notes and history and physical explain her hypothermic state and that rewarming
procedures were started and will continue until she could maintain her thermoregulation on her own.
From piecing together the emergency room notes and history and physical, I believe she was found hypothermic due to
an altered mental status from amphetamine overdose.
Clinical Manifestations: Shivering, loss of coordination, slurred speech or mumbling, confusion, drowsiness or weak
pulse are all possible manifestations seen in hypothermic patients.9
Confusion, loss of coordination and slurred speech all seemed to be present in CB’s case. However, her agitated and
combative behavior along with an altered mental status and the preceding manifestations may indicate drug overdose or
many other various issues.
Treatment: Drying and insulating a patient is imperative when dealing with hypothermia. Holding on to and
maintaining the amount of heat they have helps keep the body from shutting down further. Fluid resuscitation, CPR and
active rewarming are also treatments that should be given depending on the severity of hypothermia.8
The most information I found was that rewarming procedures were started and will continue until she can
thermoregulate herself. Once EMS arrived, noted the open windows and doors and her current status, treatment for
hypothermia should be initiated immediately.
Mortality/Prognosis: Outcome is difficult to predict since there are so many varying factors. Patients immersed in ice
water for one hour or longer have been successfully rewarmed without any permanent brain damage. However, a poor
prognosis is given to those who have evidence of cell lysis, intravascular thrombosis and nonperfusing cardiac
rhythms.8
According to her temperature and vitals, she has recovered from her hypothermic state. Prognosis for her from this
aspect looks good.
P a g e | 23
Amphetamines
Definition: Amphetamines are sympathomimetic drugs with CNS euphoria and stimulant properties. Affects may
include delirium, hypertension, seizures and hyperthermia which may lead to renal failure and rhabdomyolysis.10
Etiology/Pathology: Amphetamines enhance catecholamine release and increase the intrasynaptic levels of
norepinephrine and dopamine as well as serotonin. Stimulation of the central nervous system cause increased alertness,
euphoria, delirium and hypertension. Repeated use of amphetamines will result in dependence. Tolerance may be slow
to develop but will increase over time and affects may be altered as tolerance increases. 10
CB’s history in general is somewhat unclear. However, the history of meth use indicates that she has been a drug abuse
for some time and her clinical appearance shows it. She has bruises and lesions across her body, signs of using IV
needles for drug administration as well.
Clinical Manifestations: Increased alertness, euphoria, palpitations, tremor and diaphoresis. If an individual “binges”
on these drugs, intense fatigue and the need for long periods of sleep may ensue. If a patient overdoses tachycardia,
chest pain, nausea, vomiting and diarrhea may occur. The central nervous system effects include toxic psychosis and
acute delirium.
CB’s case was an overdose and therefore resulted in toxic psychosis, acute delirium, tachycardia and eventually
respiratory failure.
Treatment: Treatment of amphetamine abusers and overdose includes intravenous benzodiazepines, cooling
hyperthermia if the patient is hyperthermic and IV nitrates for hypertension if the patient is not responsive to
benzodiazepines.10 Rehabilitation is also recommended to prevent relapse.
Treatment for CB is going to be a long road. Along with her other medical issues, she has an amphetamine addiction
which will be hard to overcome. She seemed very compliant once she was able to be more alert. But amphetamine
overdose can lead to intense fatigue and sleep which may be why she is so compliant. She doesn’t have the energy to
fight what we are trying to do to save her. Rehabilitation and intensive medical care are her immediate treatment
requirements.
P a g e | 24
Mortality/Prognosis: Patients who continually abuse amphetamines have a poor prognosis and will die much earlier in
life. With proper treatment and rehabilitation, patients can come back from amphetamine abuse well and be functioning
members of society. This of course is dependent upon how long the patient abused the drug and what effects it had on
them.
It is hard to say how CB will do. At this time her values seem to be improving and the sepsis and infection appears to
be getting under control. However, given an unclear history it is hard to say if this may be the end of the road for her if
she has been a user for a long time. If we can wean her from ventilatory support, perhaps we can obtain more history
from her. Although it may prove difficult since she will most likely try to hide how long she has been using drugs and
possibly deny use altogether.
PLAN MOVING FORWARD (Include rationale):
1. Staphylococcus Aureus and mechanical ventilation. Continue antibiotic treatment and follow up with daily
chest x-ray, CBC. When infection is controlled wean ventilator. Hyperinflation and bronchial hygiene therapy
should be continued until discharge.
2. Acute renal failure and sepsis. Continue IV fluid therapy, antibiotic medications and monitor with CBC, renal
panel, x-ray and closely monitor kidney function with intake and output.
3. Skin lesions and Amphetamine use. Once patient is weaned of the ventilator and able to talk. Rehabilitation
consult should be provided for her to get help with her drug abuse. Continue antibiotic and aloe therapy for skin
lesions.
OVERALL IMPRESSION/STUDENT COMMENTS OR DISCUSSION:
I find it hard to believe that this is my last case study. I also feel it is my best. I put the most time into it and
the information I needed for the most part was all where it should have been when I needed it. It is sad to see
someone end up in this position all because they wanted to get high. The commercials for the Montana Meth
Project are very real and they have made a huge impact on our society in helping to reduce meth use among
people here as well as across the United States. However there are still those who are willing to try it as they
get pressured into it by peers or are led into it through gateway drugs. I sincerely feel that my patient will
find the help she needs and make the most of her life with what she has left. We have done all we can for
her, but for someone to break an addiction, they have to want to do so and they have to want better for
themselves. If she chooses not to get help then that is her decision. Hopefully she will realize this is where
she will end up in the not so distant future if she continues on this path and that maybe getting help isn’t so
bad after all.
Comment [BC16]: And hopefully got the most
out of it. As is with anyting in life, the more you give
the more you receive.
P a g e | 25
REFERENCES:
1. Pilbeam, S. P., & Cairo, J. M. (2006). Establishing the Need for Mechanical Ventilation. Mechanical
ventilation: physiological and clinical applications (4th ed., pp. 65-68). St. Louis: Mosby Elsevier.
2. Harrison's Manual of Medicine: Respiratory Failure. (n.d.). Unbound Medicine | Medical Software for iPhone,
Android, BlackBerry, Web, Windows Phone 7, & Palm. Retrieved June 5, 2011, from
http://www.unboundmedicine.com/harrisons/ub/view/Harrisons-Manual-ofMedicine/148201/all/respiratory_failure
3. Gehlbach, B., & Hall, J. (n.d.). Merck & Co., Inc. is a global research-driven pharmaceutical products
company.. Merck & Co., Inc. is a global research-driven pharmaceutical products company.. Retrieved June 5,
2011, from http://www.merckmanuals.com
4. Weil, M. (n.d.).
Sepsis and Septic Shock: Merck Manual Professional
. THE MERCK MANUALS Trusted Medical and Scientific Information. Retrieved February 12, 2012, from
http://www.merckmanuals.com/professional/critical_care_medicine/sepsis_and_septic_shock/sepsis_and_septic
_shock.html?qt=sepsis&alt=sh#v928501
5. Sepsis: Treatments and drugs - MayoClinic.com. (n.d.). Mayo Clinic. Retrieved February 12, 2012, from
http://www.mayoclinic.com/health/sepsis/DS01004/DSECTION=treatments-and-drugs
6. Silberberg, C. (n.d.). Acute kidney failure: MedlinePlus Medical Encyclopedia. National Library of Medicine National Institutes of Health. Retrieved February 12, 2012, from
http://www.nlm.nih.gov/medlineplus/ency/article/000501.htm
7. McMillan, J. (n.d.).
Acute Renal Failure (ARF): Renal Failure: Merck Manual Professional
. THE
MERCK MANUALS - Trusted Medical and Scientific Information. Retrieved February 12, 2012, from
http://www.merckmanuals.com/professional/genitourinary_disorders/renal_failure/acute_renal_failure_arf.html
?qt=acute%20renal%20failure&alt=sh
8. Danzl, D. (n.d.).
Hypothermia: Cold Injury: Merck Manual Professional
. THE MERCK MANUALS Trusted Medical and Scientific Information. Retrieved February 12, 2012, from
http://www.merckmanuals.com/professional/injuries_poisoning/cold_injury/hypothermia.html?qt=hypothermia
&alt=sh#v1114960
9. Hypothermia: Treatments and drugs - MayoClinic.com. (n.d.). Mayo Clinic. Retrieved February 12, 2012, from
http://www.mayoclinic.com/health/hypothermia/DS00333/DSECTION=treatments-and-drugs
10. O'Connor, P. (n.d.).
Amphetamines: Drug Use and Dependence: Merck Manual Professional . THE
MERCK MANUALS - Trusted Medical and Scientific Information. Retrieved February 12, 2012, from
http://www.merckmanuals.com/professional/special_subjects/drug_use_and_dependence/amphetamines.html?q
t=methamphetamine%20psychosis&alt=sh#v1027257
P a g e | 26
PATIENT CASE REPORT EVALUATION GRADE SHEET
Student: Josh Matteson
*13.
1 Diagnosis (es)
20
2 Patient’s history
20
3 Presenting signs & symptoms, Diff Dx
19
4 Description of student’s examination/assessments
19
5 Summary of laboratory data
20
6 Drug therapy including indications
and results
20
7 Respiratory modalities including
indications and results
20
8 Research of diseases
20
9 Impression, Discharge, & Comments
20
10 Overall presentation
20
11 Spelling & Grammar
20
12 References’ & Citations
20
Overall ability to relay research to your Pt’s case
60
Total points obtained
298
Total points possible
300
Percentage grade
99%
Comments:. See Study for Comments.
Great Study! Be proud of this one, use the methods learned here to learn about your patients to be an excellent RT!