case study help

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I am currently working on the following case study and need a little guidance on which way to go with the info. Any ideas? I think the patient is possibly septic r/t her leg??? I am not sure though. There is so much going on. Thanks for any input!

48year old Mexican American female admitted with fever,difficulty breathing, pleuritic chest pain, weakness, and shaky chills. Hx of flu like symptoms from approximately one week ago, took over-the-counter medications with moderate resolution of symptoms. On the day of admission, pt sleeping more than usual and seemed confused. In ER, pt's chest x-ray revealed left lower lobe pneumonia.

Health History Data:diagnosed with type 2 diabetes and hypertension about15 years ago and a "thyroid problem" for a year or two.

Prescribed Oral Medications:

Glucophage (Metformin) 500 mg twice a day.

Pravastatin(Pravachol) 40 mg daily at bed time

Levothryoxine100 mcg daily

Vasotec(Enalapril) 5 mg twice a day

Diltiazem(Cardizem) 240 mg daily

Reportfrom ER nurse

Vitals:HR 116, BP 88/56, RR 26, T 96.4°F, Wt 180, Ht 5'4",

Neuro:lethargic, responds to verbal stimuli and oriented to self

CV:heart tones distant, S1S2S4audible, capillary refill 3 > seconds

Pul:lungs clear bilaterally

GI:abdomen protuberant, hypoactive bowel sounds in all 4 quadrants

Integ:skin dry with tenting present over sternum, lips and oral mucus membranes dry and cracked, left lower leg edematous and erythematous with serous fluid oozing from lateral aspect of calf.

AdmissionLabs: SerumChemistry:

Glu 550,

K 5.6,

NA 132,

Cl 80, Cr 2.3,

BUN 82

ABGS: pH 7.30, Pa0270, PC0247, HC0320mEq/L

Hematologypanel:HCT 30. %, HGB 10.1 g/dL, RBC 3.9 x 106/µL

WBCwith differential: WBC 17,000/mm³, segmented neutrophils 79%, bandneutrophils 10%, monocytes 9%, lymphocytes 30%, eosinophils 4%, basophils 3%

Specializes in Emergency, Telemetry, Transplant.
Lactic acidosis from shock. .yes

We know the pt is somewhat acidotic (although I've seen much worse), but there is no evidence that this is (just) a lactic acidosis. Certainly an elevated lactate level would point toward shock, but even that is quite nonspecific.

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I wasnt trying to be rude..but this person is resistant to any FACTS im offering...I truely do not think this sitiation was caused by DM... look at the data..if the patient had poirly controlled DM they would be on SQ insulin..this pt is only on metformin...not saying the is no fluid deficit maybe mild but the The first part if stem clearly shows the pneumonia is the beginning of all the subsequent problems..really. .as they teach in school..the underlying problem must be fixed and treat symptoms I.e. insulin etc...

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PaO2=70=anareobic metabolism=lactic acid

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Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.
I wasnt trying to be rude..but this person is resistant to any FACTS im offering...I truely do not think this sitiation was caused by DM... look at the data..if the patient had poirly controlled DM they would be on SQ insulin..this pt is only on metformin...not saying the is no fluid deficit maybe mild but the The first part if stem clearly shows the pneumonia is the beginning of all the subsequent problems..really. .as they teach in school..the underlying problem must be fixed and treat symptoms I.e. insulin etc...
I think your teachers would be proud of you for your grasp of physiology. Applied medicine isn't always clear and patients seldom meet the exacting criteria that is presented in the texts. The pneumonia, or the infected leg, clearly began a sequale of events of events and of course more information is needed to make a definitive diagnosis.

I think we can agree this patient is sick and acidotic we just disagree on the definitive cause of the presenting labs.

Shock is hypotension with end organ injury: it classified as being due to malfunction of 1) the Pump (cardiogenic), 2 ) the Tubing (distributive), or 3) the Fluid (hypovolemic). http://www.ccmtutorials.com/cvs/Shock/page_03.htm

Hypotension and Shock are caused by a problem with Heart Rate, Stroke Volume or Peripheral Resistance.

There are only three types of shock, problems with the heart, sometimes called cardiogenic shock, problems vascular system, known as distributive shock, and loss of circulating volume, known as hypovolemic shock.

Although textbooks and examiners often emphasize the classification of shock, in the real world, it is often more effective to use the physiologic approach to shock:

  • Shock is due to inadequate blood pressure.
  • Low blood pressure is due to inadequate cardiac output or low peripheral resistance.
  • Low cardiac output is caused by a problem with heart rate or stroke volume.
  • Heart rate abnormalities: too fast (tachycardia), too slow (bradycardia).
  • Stroke Volume abnormalities: failure to receive, failure to eject, inadequate volume
  • Low peripheral vascular resistance is due to inappropriate vasodilatation.

When you graduate you will find that the reality of caring for patients is convoluted and is seldom clearly defined........Be open to opinions even if they are in conflict with your own. You are intelligent and have a great grasp on physiology. I think you will make a great nurse.

Great job! All the best.

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Part of your assignment is to present exactly these sorts of differential decisions-- you are not responsible for the medical diagnosis but it is perfectly appropriate to think if this, then that; if this, then that; if this, then that. This indicates that you are thinking ahead and alert for signs that could tell you more about the possibilities (getting more information is always a good idea while treating the immediate threat(s) to survival). Bless your faculty for teaching you so well.

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This is an excellent case study and discussion..did they ever find out what it was?

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