AC Station Week 4- Room #1
S-Situation
Pt name: David Adams, 45 year old male
Admitted under the care of Dr. Jones
Room 352, Med-Surg Unit, Tech General Hospital
Current time: 0745
B-Background
Admission Diagnosis: Unexplained weight gain, hypertension,
muscle weakness.
Past Medical History: chronic back pain, kidney stones.
Home Medications: Norco 7.5/500 q 6hours PRN pain.
Allergies: Demerol
Height: 6’2”
Weight: 242lb 110kg
Date of birth: 04-10-1968
Code Status: Full Code
A-Assessment
Mr. Adams is a 45 year old man who has been admitted from his
physician’s office for a work up related to unexplained weight
gain, hypertension, and mood changes. He is also complaining of
muscle loss, weakness, and insomnia, increased thirst and
increased urination. The patient lives with his wife and is on
medical disability because of a previous back injury.
Mr. Adams is now resting in bed after returning from a MRI a few
hours ago and has had lab work done this morning (CBC, CMP
with electrolytes, 24 hour urine cortisol, and a plasma ACTH level.
A Dexamethasone suppression test is pending). He complains of
back pain 4/10. Mr. Adams has a peripheral IV in his left AC with
LR at a rate of 120 ml/hr.
BP: 168/95 HR: 80 RR: 16 O2 Sat: 96% on room air, Temp: 98.90F
R-Recommendation
Complete an assessment, review labs, MD orders, and MAR.
Inform faculty member of suspected diagnosis, then develop basic
concept map linking assessment findings, labs, and orders.
The MRI report shows a pituitary tumor and a transsphenoidal resection has
been scheduled for tomorrow morning @ 0700.
AC Station Week 4- Room #1
Physician’s Orders
Patient ID
Name: David Adams
DOB: 04/10/1968
MRN: 111-22-333
ALLERGY: Demerol
Date: Today
1. Admit to Medical/Surgical Unit under the care of Dr. Jones
2. Diagnosis: Cushing’s disease secondary to a pituitary
tumor.
3. Allergies: Demerol
4. Code Status: Full
5. VS: Q 4 hours, weigh daily in am.
6. oxygen therapy to keep 02 sat > 96%
7. Diet: NPO except for medications pending transsphenoidal
resection @ 0700 tomorrow.
8. Strict I&O’s, collect all urine for 24 hours stop @0700 and
send to lab.
9. Activity: as tolerated
10. AM Labs: CBC, CMP with electrolytes, Plasma ACTH level,
Plasma Cortisol level, and pituitary MRI-done.
11. Dexamethasone Suppression test lab draw at 0800
12. Medications:
13. Zestril (lisinopril) 10 mg PO once daily @0800 for
treatment of high blood pressure.
15. Norco 7.5mg/500mg one to two tablets PO q 6 hours PRN
pain.
16. Ambien (zolpidem) 10 mg PO q HS for treatment of
insomnia.
17. LR at a rate of 120 ml/hr
18.
19.
20.
AC Station Week 4- Room #1
Name: David Adams
DOB: 04/10/1968
MRN: 111-22-333
ALLERGY: Demerol
CBC
WBC:
RBC:
HGB:
HCT:
PLT:
Reticulocyte Count:
Result
3
Sodium
Potassium
Cl
Carbon Dioxide
Glucose
BUN
Creatinine
GFR
Calcium
Total Protein
Albumin
Total Bilirubin
Alkaline Phosphatase
ALT
AST
Result
140 mmol/L
3.1 mmol/L
104 meq/L
22 mmol/L
142 mg/dL
18 mg/dL
1.0 mg/dL
82 ml/min/1.73mm
10 mg/dL
7.0 g/dL
4.2 gm/dL
1.3 mg/dL
130 IU/L
48 IU/L
45IU/L
Lipid Panel
Total Cholesterol
HDL
LDL
VDL
5.0-10.0 mm3
4.5 – 6.0/uL
13- 17 g/dL
40- 50 %
150- 400 K/uL
12.5 mm
5.18 m/UL
15g/DL
45 %
178 K/uL
0.3%
CMP
Reference Range
Reference Range
136-145 mEq/L
3.5-5.0 mEq/L
98-106 mEq/L
23-30 mEq-L
70-110 mg/dL
10-20 mg/dL
0.6-1.2 mg/dL
62-120 ml/min/1.73mm
8.2-10.2 mg/dL
6.3-8.0 gm/dL
3.5-5.5 gm/dL
0.2- 1.3 mg/dL
38-126 IU/L
9-52 IU/L
14-46 IU/L
Result
Reference Range
220 mg/dL
45 mg/dL
140mg/dL
40 mg/dL
Less than 200 mg/dL
M :>45 mg/dL F:>55 mg/dL
Less than 130 mg/dL
7-32 mg/dL
45 mcg/dl
Pending
6-21 mcg/dl
<1.8mcg/dl
350 mcg/24hr
98pg/ml
10-100 mcg/24hr
<80pg/ml in am, <50pg/ml in
pm
Add-on Lab
Plasma Cortisol
Dexamethasone
Suppression test
24 hour urine cortisol
Plasma ACTH
Lab Results:
Date: Today
Time: 0400
AC Station Week 4- Room #1
Tech General Hospital
24 HOUR MEDICATION ADMINISTRATION RECORD
Order
Date
today
today
today
DC
Date
Treatment and
Frequency
LR @ 120 ml/hr IV
Due
Time
0700-1900
1900-0659
0700-1900
1900-0700
Cont.
Zestril(lisinopril) 10 mg
PO daily @0800 for
treatment of hypertension
Ambien(zolpidem) 10 mg
PO @ HS for treatment of
insomnia.
today
today
today
today
PRN meds
today
Norco(hydrocodone), one to
two tablets PO q 6 hrs, PRN
pain.
today
today
today
today
Initial that MAR has been
Verified/Reconciled:
Initial
Signature
Initial
Signature
Patient I.D.
Name: David Adams
DOB: 04/10/1968
MRN: 111-22-333
ALLERGY: Demerol
AC Station Week 4- Room #1
Mr. David Adams (Cushing’s disease)
Assessment:
VS: 168/ 95 HR: 80 RR: 16 O2 Sat: 96% on room air. Temp: 98.90F
Pain: 4/10 Back pain unrelieved by position changes.
Head: PERRLA @ 4 mm, GCS 15, AOx3. Patient has a notably rounded face (moon face) with red
cheeks (plethora). Patient is emotionally labile.
Neck: Excess adipose tissue on back of neck (buffalo hump).
Chest: truncal obesity noted.
Cardiovascular: S1, S2 present, regular rate and rhythm. Blood pressure elevated at 168/95.
Abdominal: Pendulous abdomen with active bowel sounds in all four quadrants. Last known
BM was yesterday.
GU: Voids without pain; Last void was early this morning – slightly cloudy, amber, and no odor.
UA shows glycosuria and hypercalciuria.
Skin: The patient has thin, fragile skin with areas of purple striae over the abdomen. Areas of
bruising noted on extremities.
MS: Muscle wasting is noted in the extremities, patient complains of back pain, fatigue,
weakness and has an awkward gait.
**Suggested lab to help students if they are struggling: 24 hour urine collection,
Dexamethasone suppression test, plasma cortisol, K+, UA, CT of pituitary gland.