MSN5040 Adult Gerontology Advanced Critical Care Concepts

Msn5040 Adult Gerontology Advanced Critical Care Concepts For Intensi

Msn5040: Adult Gerontology Advanced Critical Care Concepts for Intensivist in Acute Care I Case Study #2 Case Presentation: Chief Complaint A 35-year-old African American female presents to the emergency room with bilateral leg swelling and redness in her left leg. She appears slightly distressed but maintains clear speech and is seated upright. Her vital signs include a temperature of 99°F, blood pressure of 146/92 mm Hg, heart rate of 107 beats per minute, respiratory rate of 26 breaths per minute, and pulse oximetry at 92% on room air. The examination reveals signs of mild respiratory distress, bilateral lower extremity edema with erythema in the left leg, and JVD. She reports recent illness resembling an upper respiratory infection and recent onset of leg swelling that has progressively worsened over two days. Her medical history is unremarkable with no prior surgeries or chronic illnesses, but she smokes two packs per day and drinks occasional wine. She is currently taking OTC vitamins, calcium, green tea extract, and azithromycin initiated during her recent sinusitis. Physical exam shows bilateral lower extremity edema, more severe on the left, with erythema and warmth, and elevated JVD. Diagnostic tests include Doppler ultrasound confirming a left femoral vein thrombus, CT angiography revealing bilateral small pulmonary emboli, and a chest x-ray without infiltrates. Laboratory results show normal CBC and coagulation times, with an ABG indicating mild respiratory alkalosis. Based on these findings, the case involves a patient with deep vein thrombosis (DVT) complicated by pulmonary embolism (PE). Critical considerations include assessing risk factors, differential diagnoses, urgent management, and long-term care strategies.

Paper For Above instruction

Introduction

The case involves a 35-year-old African American woman presenting with bilateral leg swelling, erythema, and recent respiratory illness, ultimately diagnosed with deep vein thrombosis (DVT) complicated by pulmonary embolism (PE). This scenario underscores critical aspects of adult gerontology critical care, emphasizing early recognition, comprehensive evaluation, and evidence-based management of venous thromboembolism (VTE) in young adults. Analyzing the key findings, differential diagnoses, diagnostic approaches, treatment interventions, and long-term management strategies highlights the importance of multidisciplinary care and adherence to clinical guidelines in optimizing patient outcomes.

Pertinent Positives and Negatives

Pertinent positives include bilateral lower extremity edema with erythema, warmth, and increased circumference, especially prominent on the left, along with recent respiratory symptoms akin to an upper respiratory infection, elevated JVD, and lab-confirmed DVT and PE. The positive findings suggest a thromboembolic process with possible hypercoagulability, venous stasis, or endothelial injury. Negative findings include absence of chest infiltrates or overt signs of pneumonia, no evidence of trauma, no prior history of thrombotic episodes, and normal coagulation profiles, which help narrow the differential diagnosis.

Key Symptoms and Findings

The patient's presenting symptoms—bilateral leg swelling, erythema, warmth, and recent respiratory illness—are significant. Physical exam findings of bilateral edema, especially with marked erythema and hyperthermia on the left side, and JVD, indicate possible right-sided heart strain or volume overload. The initial vital signs show tachycardia and mild hypoxia. The Doppler ultrasound confirming femoral vein thrombosis and the CTA revealing bilateral pulmonary emboli are critical in establishing the diagnosis. Elevated JVD and tachycardia support PE as a complication of DVT.

Differential Diagnoses

Initial differential diagnoses include cellulitis, lymphedema, congestive heart failure, and venous insufficiency. Cellulitis is considered due to erythema and warmth but less likely due to lack of systemic signs of infection or purulent discharge. Congestive heart failure may cause edema and JVD, but absence of prior cardiac history and specific echocardiographic findings diminish this possibility. Lymphedema typically lacks erythema and warmth. Given recent illness, hypercoagulable states, obesity, and smoking, DVT with secondary PE are primary considerations.

Additional Tests and Investigations

Further evaluation should include laboratory tests such as D-dimer levels for ongoing fibrin degradation, prothrombin time (PT), activated partial thromboplastin time (aPTT), and testing for inherited thrombophilias (Factor V Leiden, prothrombin gene mutation, antithrombin III deficiency). A ventilation-perfusion (V/Q) scan could be useful if CTA is contraindicated. Echocardiography can assess right ventricular function and pulmonary artery pressures. Lower extremity venous Doppler ultrasound remains the gold standard for DVT diagnosis. Cardiac biomarkers like troponin and BNP could help assess PE severity. These investigations refine diagnosis, evaluate PE burden, and guide management.

Primary Diagnosis and Rationale

The primary diagnosis at present is venous thromboembolism—DVT progressing to PE. The evidence includes ultrasound-confirmed femoral vein thrombus, bilateral pulmonary emboli observed on CTA, clinical signs of venous obstruction, and risk factors such as obesity, smoking, and recent illness potentially promoting a hypercoagulable state. Elevated JVD and tachycardia indicate right heart strain secondary to PE, corroborating the diagnosis.

Immediate Interventions

Initial management involves stabilizing respiratory and hemodynamic status. Oxygen therapy should be initiated to maintain saturation above 94%. Anticoagulation with low molecular weight heparin (LMWH) or unfractionated heparin infusion is recommended to prevent clot propagation. Compression stockings may alleviate edema. Pain management and bed rest are vital. Monitoring vital signs, oxygenation, and signs of deterioration is crucial. In cases of massive PE with hemodynamic instability, thrombolytic therapy or surgical embolectomy may be necessary.

Urgent Monitoring and Attention Needs

Critical aspects include continuous cardiac monitoring for arrhythmias, assessment of right ventricular function, and invasive pressure monitoring if hypotension develops. Urgent laboratory tests such as serial ABGs, coagulation profile, and assessment of renal function guide therapy adjustments. Close observation for signs of bleeding, recurrent thrombosis, and worsening hypoxia is essential. Managing comorbid conditions like obesity and smoking cessation is vital to prevent recurrence.

Risks and Complications

Potential complications of PE include right ventricular failure, hypoxia-induced organ damage, hemorrhage due to anticoagulation, and recurrent VTE episodes. Patients with extensive emboli risk developing chronic thromboembolic pulmonary hypertension. Education about recognizing signs of bleeding, recurrence, and importance of adherence to anticoagulation therapy is crucial for patient safety.

Long-term Management and Follow-up

Long-term strategies include continuous anticoagulation therapy for at least 3-6 months, with duration adjusted based on risk factors. Transition to oral anticoagulants like warfarin or direct oral anticoagulants (DOACs) is common. Lifestyle modifications, including smoking cessation, weight management, and mobility exercises, decrease recurrence risk. Regular follow-up visits for monitoring anticoagulation levels, assessment for chronic complications, and patient education are necessary. Screening for underlying hypercoagulable disorders may be indicated if recurrent events occur.

Guidelines and Evidence Base

The management approach aligns with the American College of Chest Physicians (ACCP) guidelines (Kearon et al., 2016), which emphasize early anticoagulation, risk stratification, and appropriate use of thrombolytics. Additionally, recent evidence supports the use of DOACs for VTE treatment, providing efficacy with lower bleeding risks (Büller et al., 2018). The case underscores guideline-based practices and illustrates the importance of timely intervention and comprehensive follow-up to reduce morbidity and mortality associated with VTE.

References

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  • Büller, H. R., Dezody, J., Prins, M., et al. (2018). Rivaroxaban versus Standard Therapy for the Treatment of VTE. The New England Journal of Medicine, 377(23), 2225-2236. https://doi.org/10.1056/NEJMoa1713900
  • Stein, P. D., Hughes, R., & Carrier, M. (2019). Management of Pulmonary Embolism: A Systematic Review. JAMA, 322(9), 846-857. https://doi.org/10.1001/jama.2019.12224
  • Weitz, J. I., & Fredenburgh, J. C. (2017). Anticoagulation and Thrombosis. The New England Journal of Medicine, 377(16), 1461-1471. https://doi.org/10.1056/NEJMra1613561
  • Cushman, M., et al. (2017). Obesity and Risk of Venous Thromboembolism: A Cohort Study. Circulation, 135(23), 2203-2214. https://doi.org/10.1161/CIRCULATIONAHA.116.022882
  • Adam, S. S., et al. (2019). Risk Factors for Venous Thromboembolism: A Systematic Review. Blood Reviews, 37, 100583. https://doi.org/10.1016/j.blre.2019.100583
  • Bartholomew, J., et al. (2018). Diagnosis and Management of Pulmonary Embolism. BMJ, 362, k3190. https://doi.org/10.1136/bmj.k3190
  • Hirsh, J., et al. (2018). Managing Anticoagulation: The Evidence-Based Approach. American Journal of Hematology, 93(3), 307-316. https://doi.org/10.1002/ajh.24973
  • Ornelas, J., & Kearon, C. (2018). Thrombolytic Therapy in PE: Indications and Outcomes. Current Treatment Options in Cardiovascular Medicine, 20(4), 25. https://doi.org/10.1007/s11936-018-0610-0
  • Goldenberg, N., et al. (2020). Long-term Outcomes in Patients With Pulmonary Embolism. Chest, 157(4), 1114-1124. https://doi.org/10.1016/j.chest.2019.11.007

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