Case Study: Fever - page 3
The following is a case involving a young male who presents with fever associated with respiratory symptoms. This is based on a real case. The events leading to his hospitalization and his course in... Read More
Jun 25, '13Not an ED nurse.. But I'll give this a shot. There are certain things that are "glaring" at me when I read this.
1) Just moved to Central Valley, new job with father in a "small business" (that's a clue), Philipino decent
2) Mild respiratory distress, Joint pain, BILATERAL SHIN RASH
After the first post, it's still hard to know what could be going on but I knew those facts were important
Second post - Things that stood out
1) Chest X-ray abnormal, you stated it was consistent with bacterial infx
2) Elevated WBC - Infectious process going on
3) Increasing respiratory distress only after 1 hour under your care
Patient is going from mild respiratory distress to acute, he has Chest X-ray that is consistent with bacterial infx. Now at this point it could still be anything, but I don't think pneumonia, influenza has this kind of presentation especially with a young healthy man. The difference here is that he just moved to Central Valley with his father and is working at his business. Why was this screaming at me? I don't know. I cheated a little and googled Central Valley, Flu, rash, joint pain or some kind of combo, and Valley Fever popped up.
Valley fever is caused by a fungus called Coccidioides immitis or Coccidioides posadasii that thrive in desert soils. The case presentation is consistent with Valley Fever: Rash, Fever, Joint pain, chest pain, abnormal chest x-ray etc. I'm willing to bet the father either works in construction or landscaping that has exposed the patient to this fungus.
Culture would need to be obtained to confirm diagnosis, IV antifungals should be started after positive culture returns, IV fluids, tx of symptoms, monitor pain levels.
As for the third post, pre intubation the patient was in respiratory distress and had increased RR to compensate for his inadequate pulmonary function. Post intubation the patient's ventilations are set to 20 so his RR will read 20 (I think?), his HR is lower because he is no longer in distress and/or because the sedating effects of propofol. I believe propofol is causing the b/p to drop although IMMediately post intubation I do not think it is a reason for alarm. Monitor patient vital signs q5min for at least 30mins and if b/p does not go up then consider titrating propofol.
Jun 25, '13I don't think anyone should be surprised that Rolando dropped his pressure. Like I said earlier he has been feeling sick for a while, tachypneic, probably is infected and just got sedated. Run those fluids in! Titrate down propofol as tolerated. Once patient's pressure is up a little roll him on over to the ICU. If he doesn't respond to fluid resuscitation he'll probably get lined for pressors and to check a CVP. An a-line would be good for labile blood pressures and frequent ABGs. Now that he has an ETT maybe we could do a bedside bronch once he stabilizes. He should be getting broad spectrum antibiotics at this point and coverage for fungal source (fluconazole?).
Jun 25, '13Quote from juan de la cruzCentral Valley, huh? Hypoxia without hypercarbia? Valley fever.Rolando was appropriately triaged as emergent and was placed on Airborne Precautions in negative room pressure. The triage nurse appropriately secured an order for high flow nasal cannula. You are now his nurse in the ED.
Orders were for:
Respiratory Viral Panel, Sputum bacterial and gram stain, Legionella serum Ab, Pneumococcal serum Ag, Sputum for AFB. You were able to send all the appropriate specimens for these tests.
You were also asked to obtain ABG with lactate, CBC, Basic Metabolic Panel, and Coagulation Studies. Blood cultures were ordered. UA with tox screen was also ordered.
A portable CXR was obtained.
Available labs revealed:
Ph 7.40 pCO2 37 pO2 56 HCO2 22 BE 0 Sat 90% Lactate 2.5 on HF at 100% FiO2
WBC 18,000 Hgb 16 Hct 48 Plt 300 (+) Eosinophilia
Na: 140 K 4.0 Cl 100 CO2 22 BUN 15 Crea 0.5 Gluc 87
PT 14 INR 1.1 PTT 23
negative for UTI or drugs
Rolando is working a bit harder to breathe after 1 hour of being under your care. What would you anticipate next?
Jun 25, '13Quote from GrnTeaI tried to edit but got frozen out somehow. I meant to continue:Central Valley, huh? Hypoxia without hypercarbia? Valley fever.
I didn't read any other comments before posting, I swear. I lived in CA and saw this presentation often. I'm thinking this poor boy buys himself a lot of sedation and an FIO2 of 1.0 and all the PEEP he can handle to get his FIO2 down and his PaO2 up. He gets amphoterrible or whatever else is specific for mycoses these days. If he is lucky he does not end up in a box.
Jun 25, '13I've never looked much into Valley Fever before, but researching it now, it seems this case fits the bill.
Nurse's role in RSI: Monitor heart rate, oxygenation, respiratory rate, and s/sx of pain, educate and reassure patient throughout procedure, ensure adequate IV access, administer drugs for sedation, paralysis, and to maintain BP, ensure necessary orders are ordered both for during RSI and to maintain patient stability and comfort afterwards (continued sedation, eye drops, fluids, blood pressure support, lab work), place foley and NG tube shortly after intubation if not already done.
The drop in blood pressure is related to sedation from the propofol. Increased oxygenation and respiratory rate of 20 related to vent settings. Drop in HR related to relaxation, and better oxygenation. I'm okay with the BP for now, but he may need increased fluids, decreased propofol, or a pressor if it drops further.
Treatment at this point likely involves transfer to ICU and antifungal therapy, likely with amphotericin as he is critically ill.
Jun 26, '13Quote from danceyrunSo does he have Vally fever? I L O V E these threads!!! So fun (nerd alert).
I am with you on that!!
Jun 27, '13Just a question to the OP, did an RN administer the propofol? Or a CRNA? I agree with the rest of the posts/comments already posted. Good case study. Has my old brain gears spinning...
Jul 1, '13Quote from juan de la cruzI love these case studies. I find them very interesting. I am a newer ED nurse in a small community hospital and in our ED it really depends on the MD. Since many times there is only 1 MD on and he/she is the one intubating it will actually be one of the ED nurses who prepares the RSI meds. and pushes them while the MD is at the head of the bed ready to intubate. If it is during the day and we have another MD or PA on they might come in and do the meds. but it is usually the RN. I have had to do it once so far and my hands were shaking the whole time.A rapid sequence intubation followed. You will be assisting with this. A question, for the ED nurses in community hospital settings, what are your roles in this procedure? do you administer induction agents (Opioid/Hypnotic and Paralytics)? Just thought I'd ask.
Jul 2, '13Of course the RN gives them. No different from any other IV meds in that regard. You'll get used to it pretty fast.