The subject of this paper, who shall be known as Bill, is an 82-year old male with a long history of coronary artery disease, | |congestive heart failure and aortic valve replacement. His condition had been stable until about four days prior to admitting to the | |ED. While visiting with his daughter he became increasingly short of breath and was subsequently transported to the emergency | |department by ambulance. This client has experienced an exacerbated state of CHF. On admission the patient was confused and | |exhibited extreme shortness of breath, fluid in the lungs and 3+ edema bilaterally in his lower extremeties. His admitting vital | |signs were: BP 130/70, HR 100, Resp 26, SpO2 70%.
Untreated the condition could have led to myocardial infarction or acute | |respiratory failure, renal failure, and ultimately death. | |Background | |Bill moved from Washington state approximately 2 months ago. He is married and lives locally. He denies using tobacco or alcohol. | |He Has two children; neither lives locally, nor has limited contact with them due to vicinity. His wife is wheel chair bound and | |requires full assistance with transferring and ADL’s. Bill is a retired machinist and is currently collecting a union pension and | |social security benefits, and qualifies for medicare. His wife is eligible for and collects disability. | | | | | | | | | | | | Physical Assessment Findings: My assessment of this patient was two days after admission. Most of the extreme symptoms he exhibited on admission had mostly been resolved. He did however still have moderate edema in his lower extremities. His lungs sounds were also drastically improved although they were slightly decreased with coarse crackles in the bases. He complained of shortness of breath. His oxygen saturation was 95% on 2 liters oxygen via nasal cannula. The patient complained of exertional fatigue and dizziness upon sitting up.
He had full sensation in his upper extremities, but some numbness in his feet due to long standing diabetic neuropathy. He was alert and oriented to time, place, person. Pupils were equal and reactive to light and accommodated. Bowel sounds were present in all four quadrants. His abdomen was slightly distended, and he complained of a loss of appetite. He stated he was having mild myalgia but within his pain comfort goal of 3/10. Peripheral pulses were strong in upper extremities with thready pedal pulses bilaterally. Capillary refill was appropriate in all extremities. He has normal heart sounds with a systolic murmur. Vital signs taken by the PCT were reported as: BP 107/56, HR 75, RR 16, Temp 36. C, SaO2 90% 2L O2 via nasal cannula. The finding of my assessment all correlate with the admitting diagnosis of exacerbate state of CHF. The fatigue is most likely due to the lack of adequate perfusion caused by ineffective pumping of the heart and the pulmonary edema. The crackles in the lung bases are a result of the excessive amount of fluid that was initially in his lungs. Due to being on diuretic therapy (Bumex) the majority of the fluid in the lungs had cleared. Also due to the diuretic the majority of the anasarca was resolved, and only moderate peripheral edema was present. The other findings were normal for this patient. DIAGNOSTIC LABORATORY TESTS | | | | |Lab Test |Normal Range |Results |Significance For This Patient | |CBC |Hct |37-47% |39. 2 L |Often seen with fluid volume excess. Possible iron deficiency anemia. Abnormalities in RBC size (RDW 17. 8) may | | | | | |alter values. Could possibly be due to diabetic nephropathy. | | |Hgb |13. 4-18. 0 g/dL |13. 3 L |Often seen with fluid volume excess. Possible iron deficiency anemia.
Could possibly be due to diabetic | | | | | |nephropathy. | | |RBCs |4. 2-5. 8 10^6/uL |4. 49 L |Often seen with fluid volume excess. Possible iron deficiency anemia. Could possibly be due to diabetic | | | | | |nephropathy. | | |MCV |80-100 fL |87. 2 | | | |MCH |27. 0-33. 0 pg |29. | | | |MCHC |32. 0-36. 0 g/dL |33. 8 | | | |RDW |11. 0-15. 0% |17. 8 H |Pt was previously on iron supplements, common cause of increased RDW is iron deficiency anemia. Possible need | | | | | |to restart iron supplementation. | | |WBC |3. 8-10. 8 10^3/uL |6. 8 | | | |*Segs |45. 2-75. 6% |78. H |Neutrophil/Seg counts are often increased during physical stress, or with tissue necrosis that might occur | | | | | |after a myocardial ischemia. This pt. may also have a pulmonary bacterial infection. Sputum cultures should | | | | | |be ordered. | | |*Lymph |19. 0-46. 0% |9. 9 L | | | |*Mono |2. 3-11. 2% |7. | | | |*Eos |0. 0-6. 0% |3. 9 | | | |*Baso |0. 0-6. 0% |. 1 | | | | PLTS |150-400 10^3/uL |169 | | | |MPV |7. 5-11. 5 fL |7. | | | |PT |11. 0-12. 5 |21. 6 H |Pt. is on long term coumadin therapy to reduce risk for PE and CVA due to heart condition. Pt. is at risk for | | | | | |hemorrhage, possible bleeding should be assessed routinely. | | |INR |therapeutic |1. 9 |Levels are just slightly below therapeutic range.
Possibly collaborate with physician to increase dose. | | | |range:2. 0-3. 5 | | | |Electrolytes | Na |136-145 |136 L |Pt. levels are only slightly decreases. Low levels are a result of Bumex therapy, a strong loop diuretic which | | | | | |inhibits the body’s ability to reabsorb sodium. | | | K |3. 5-5 |4. | | | | Cl |98-106 |103 | | | | CO2 |23-30 |26 | | | | Angap | |7. 0 | | | | Gluc |70-100 |125 H |Glucose levels slightly elevated, levels are related to condition of diabetes mellitus.
Lab value not critical | | | | | |for this patient. | |Renal Function |BUN |10-20 |52 H |Elevated BUN is consistent with CHF, indicates renal insufficiency due to poor renal perfusion. Should be | | | | | |evaluated aggressively for further s/s of renal damage. Consult with physician regarding unchanged levels. | | |Creat |. 06-1. 2 |3. 0 H |Increased levels indicate renal insufficiency due to reduced renal blood flow.
Diabetic nephropathy could also| | | | | |be a factor in the increase. Physician should be consulted for unchanged or increased values. | |LFT |AST |0-35 |27 | | | |ALT |4-36 |15 | | |Other Metabolic |Bilirubin |0. 3-1. 0 |. | | |Values | | | | | | |CRP | |Not available | | | |Alkaline Phosphatase |30-120 |73 |Indicates no liver damage/involvement | | |AST |0-35 |27 |Indicates no liver damage/involvement | | |ALT |4-36 |15 |Indicates no liver damage/involvement | | |Pre-Alb | |Not available | | | |Amylase | |Not available | | | |Lipase | |Not available | | | |Ammonia | |Not available | | |ABG’s | pH | |Not available | | | | PCO2 | |Not available | | | | HCO3 | Not available | | | | PO2 | |Not available | | | | O2 Sats | |Not available | | | | O2 CT | |Not available | | | | HbCO | |Not available | | | | MHb | |Not available | | |Micro |Sputum | | | | | |Catheter | | | | | |Urine | | | | | |Other BNP |