Hypothetical Case Study Of A 68-Year-Old Patient Who Has Bee ✓ Solved

Hypothetical case study of a 68-year-old patient who has been

Hypothetical case study of a 68-year-old patient who has been transferred to the ward. Background: Type 2 diabetes, Barrett's oesophagus, heart failure. At start of shift patient was curled in bed, weak, receiving oxygen 4 L/min and had a nasogastric tube and urinary catheter. Alert and orientated. Initial observations: Temperature 37.8°C, Heart rate 98 bpm, Respiration 22 cpm, Blood pressure 66/48 mmHg, Oxygen saturation 97%, NEWS2 score 8/10. Critically discuss initial assessment, planning, monitoring and treatment.

Patient then deteriorated: Temperature 38.2°C, Heart rate 118 bpm, Respiration 22 cpm, Blood pressure 80/42 mmHg, Oxygen saturation 94%; systolic BP rose to about 90 mmHg but persisted in the 80s. Critically analyse management and interventions including blood tests and treatments, using NICE (UK) guidelines. Patient was later moved to intensive care. Critique timing of referral and management protocol and reflect on practice and what could have been changed to prevent or alter the outcome.

Also answer: What are the design principles underlying component-based software engineering (CBSE) that support construction of understandable and maintainable software? You have been asked to design a secure system requiring strong authentication and authorization and confidentiality of inter-component communications. Suggest the most appropriate client–server architecture for this system and, with reasons, propose how functionality should be distributed between the client and server.

Paper For Above Instructions

Executive summary

This paper critically examines the initial assessment and subsequent management of a 68-year-old ward patient with multiple comorbidities who presented with hypotension, an elevated NEWS2 and later deterioration consistent with septic shock. It applies NICE and international sepsis guidance to recommend monitoring, investigations and treatments, critiques timing of escalation to intensive care, and reflects on preventable actions. The paper then addresses CBSE design principles and proposes a secure client–server architecture appropriate for strong authentication, authorization and confidential inter-component communications.

Clinical assessment and initial priorities

On arrival the patient had a critically low blood pressure (66/48 mmHg), a NEWS2 of 8 and mild pyrexia. These findings constitute an urgent clinical deterioration: an immediate bedside assessment by a senior clinician and an urgent treatment escalation should have been triggered (NEWS2 escalation protocols) (Royal College of Physicians, 2017). The initial assessment must rapidly establish airway, breathing, circulation and disability, identify sources of infection (urinary catheter, NG tube), and determine perfusion and end-organ dysfunction.

Immediate investigations and monitoring

Per NICE and sepsis guidelines, urgent investigations should include blood cultures (before antibiotics if this will not delay treatment), serum lactate, full blood count, renal function and electrolytes, liver function tests, coagulation profile, C-reactive protein, blood glucose, arterial/venous blood gas and bedside urine output monitoring (NICE NG51; Surviving Sepsis Campaign) (NICE, 2016; Rhodes et al., 2017). Continuous cardiorespiratory monitoring and repeated NEWS2/obs (every 15–30 minutes initially) are essential. Given heart failure history, baseline ECG and point-of-care ultrasound (if available) help distinguish cardiogenic vs distributive shock.

Initial resuscitation and differential management considerations

Guidelines recommend rapid administration of broad-spectrum intravenous antibiotics within one hour of suspected sepsis with shock, and initial fluid resuscitation with crystalloid 30 mL/kg unless fluid overload risk is prohibitive (Surviving Sepsis Campaign; NICE) (Rhodes et al., 2017; NICE, 2016). For this patient, heart failure increases the risk of fluid overload; however, untreated hypovolaemia and distributive shock risk organ failure. A pragmatic approach is modest boluses (e.g., 250–500 mL), frequent reassessment of response and use of bedside ultrasound to guide fluid responsiveness. If hypotension persists despite initial fluid, early vasopressor (norepinephrine) to maintain MAP ≥65 mmHg is indicated (Rhodes et al., 2017). Oxygen therapy was in place, but strict titration to target saturations and monitoring for respiratory failure is required.

Critique of observed deterioration and escalation

The progression to persistent systolic BP in the 80s with tachycardia (118 bpm) and fever is consistent with septic shock. Given the initial BP of 66/48 and NEWS2=8, escalation to critical care and senior review should have been immediate; any delay represents suboptimal adherence to escalation protocols (Royal College of Physicians, 2017; NICE, 2016). Early vasopressor initiation and consideration of ICU-level haemodynamic monitoring (invasive arterial line, central venous access, lactate-guided resuscitation) are recommended when hypotension persists after initial fluid (Rhodes et al., 2017). Timely transfer to ICU for vasopressor support and close organ support is appropriate; critique focuses on whether senior review, antibiotic administration and sepsis bundle elements occurred early enough.

Reflection and changes to improve outcome

Improvements would include automatic sepsis screening for any NEWS2 ≥5/triggering criteria, immediate senior/critical care review when MAP

CBSE design principles for understandable, maintainable systems

Key CBSE principles: modularity, high cohesion and low coupling, clear and minimal interfaces, component encapsulation, separation of concerns, well-specified contracts and versioning, replaceability and reusability, and standardized communication patterns (Szyperski, 1998; Heineman & Councill, 2001). These principles improve understandability and maintainability by isolating functionality, minimizing ripple effects of change and enabling rigorous testing of components.

Secure client–server architecture recommendation

For a system requiring strong authentication/authorization and confidentiality of inter-component communications, a layered client–server architecture with an API gateway and dedicated authentication/authorization service is recommended. Use an architecture incorporating:

• Authentication and identity provider (IdP) implementing NIST SP 800‑63B practices (strong multi-factor authentication, secure token issuance) (NIST, 2017).
• API gateway that centralises TLS termination (prefer TLS 1.3), rate-limiting and initial request validation (RFC 8446) (IETF, 2018).
• Microservices or components communicating over mutual TLS (mTLS) with short-lived certificates and strict access control lists; service-to-service auth using signed tokens (JWTs with appropriate claims) and mTLS to prevent interception and replay (OWASP guidance).
• Centralized authorization service (RBAC or ABAC) that evaluates access policies and returns authorization decisions; enforce authorization server-side to prevent client-side manipulation (OWASP; NIST).
• Secure key management using an HSM or cloud KMS for cryptographic keys and token signing.

Distribution of functionality

Clients should implement presentation and minimal input validation, credential capture for MFA, and local encryption of sensitive caches. All critical business logic, access control decisions, audit logging, data validation, and persistence must reside server-side in trusted components. Authentication and token issuance should be centralised in the IdP; the API gateway performs initial validation, then forwards requests to microservices that validate tokens and request authorization decisions from the central policy service. This distribution minimises the trusted surface on clients, centralises policy enforcement, and simplifies security updates while conforming to CBSE modularity and interface contracts (Szyperski, 1998).

Conclusion

Clinically, immediate senior review, adherence to sepsis bundles (lactate, cultures, antibiotics, fluid judiciously, early vasopressor) and prompt ICU escalation when hypotension persists are essential improvements for this case (NICE; Surviving Sepsis Campaign). In software design, CBSE principles combined with a centralised, defence-in-depth client–server architecture using strong authentication, mTLS and server-side authorization deliver confidentiality and maintainability. Both domains benefit from clear interfaces, early escalation/decision points and systematic protocols.

References

• NICE. Sepsis: recognition, diagnosis and early management (NICE Guideline NG51). National Institute for Health and Care Excellence; 2016. https://www.nice.org.uk/guidance/ng51
• Rhodes A, Evans LE, Alhazzani W, et al. Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock. Intensive Care Med. 2017;43(3):304–377. https://doi.org/10.1007/s00134-017-4683-6
• Royal College of Physicians. National Early Warning Score (NEWS) 2. 2017. https://www.rcplondon.ac.uk/projects/outputs/national-early-warning-score-news-2
• NIST. Digital Identity Guidelines: Authentication and Lifecycle Management (SP 800-63B). National Institute of Standards and Technology; 2017. https://pages.nist.gov/800-63-3/sp800-63b.html
• Szyperski C. Component Software: Beyond Object-Oriented Programming. Addison-Wesley; 1998.
• Heineman GT, Councill WH (eds). Component-Based Software Engineering: Putting the Pieces Together. Addison-Wesley; 2001.
• IETF. The Transport Layer Security (TLS) Protocol Version 1.3 (RFC 8446). 2018. https://tools.ietf.org/html/rfc8446
• OWASP. Authentication Cheat Sheet. OWASP Foundation; 2019. https://cheatsheetseries.owasp.org/cheatsheets/Authentication_Cheat_Sheet.html
• NICE. Acute heart failure: diagnosis and management (NG106). National Institute for Health and Care Excellence; 2018. https://www.nice.org.uk/guidance/ng106
• Vincent JL, Opal SM, Marshall JC, Tracey KJ. Sepsis definitions: time for change. Lancet. 2013;381(9868):774–775. https://doi.org/10.1016/S0140-6736(12)61815-7