MSN5040 Adult Gerontology Advanced Critical Care Conc 345947

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 arrives at the emergency room complaining of bilateral leg swelling and redness in her left leg. She sits up in the bed, appearing slightly distressed but manages clear speech without difficulty. Her vital signs indicate 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. General Survey and History of Present Illness Immediate attention is directed towards assessing the patient's wellbeing and response to her current health condition. A thorough evaluation of her airway, breathing, and circulation is paramount to ensure adequate support. Upon initial observation, she is seated upright in bed, displaying signs of increased respiratory rate at 26 breaths per minute. Notably, she exhibits no use of accessory muscles and presents with a pink complexion, devoid of any signs of sweating or asymmetry. Communication with the patient is clear as she greets with a composed 'hello.' As no accompanying person is present, crucial information relies on her ability to provide it. Presently, she appears to be managing her discomfort reasonably well despite mild respiratory distress. The patient, while well developed and nourished, is noted to be obese, attired in slightly worn yet clean clothing. Her chief complaint revolves around bilateral leg swelling, with recent redness onset in her left leg. She recalls a progression of ankle swelling over the past two days, escalating upwards towards the knee and thigh. Denying any associated pain, lesions, trauma, or recent surgeries, she expresses concern as the swelling continues to exacerbate without alleviation. This is an unprecedented episode of leg swelling for her. Preceding the swelling, she endured a subjective fever, runny nose, nonproductive cough, and sore throat, confining herself to bed for three days. Interestingly, her nephew exhibited similar symptoms before her illness. No prior medical records are available for review at this facility. Her vital signs at initial triage reveal a temperature of 99°F, blood pressure reading of 146/92 mm Hg, heart rate of 107 beats per minute, and a respiratory rate of 26 breaths per minute, with pulse oximetry registering 92% on room air. Past Medical History o The patient denies a medical history involving heart disease, lung disease, liver problems, or cancer. She confirms no history of diabetes or pregnancy. While enduring a tragic loss with both parents in an auto accident a decade ago, no chronic illnesses were reported. However, her sister has a medical history involving diabetes and hypertension. The patient denies a family history involving myocardial infarction, stroke, cancer, anemia, clotting disorders, or congenital defects. Past Surgical History o The patient has never had surgery. Social History o Occupationally, she works as a computer programmer, leading a sedentary lifestyle and lives with a male partner. Habitually, she has been a smoker for the past 20 years, consuming two packs a day, alongside occasional wine intake, without any reported liquor or illicit drug use. Medications o Her current medication regimen includes OTC daily vitamins, calcium supplements, green tea extract, and azithromycin, which she initiated on day 3 of her recent illness to address sinusitis. Review of Systems o Constitutional: Bedridden with URI 3 days and states she did not have an appetite and did not get out of bed often to get fluids or food. She denies chills but states she thought she had a low-grade fever. o Head/eyes/ears/nose/throat: Winter sinusitis à— 4 years, treated with azithromycin. Started this medication on day 3 of recent URI symptoms, which included runny nose (clear secretions), nonproductive cough, and sore throat. Denies pain or discomfort in ears, endorses sore throat with recent illness but this is now improving. o Cardiovascular: Denies chest pain, palpitations, and irregular heartbeats, endorses bilateral leg edema. o Pulmonary: Denies orthopnea or shortness of breath until today, but today she states she feels better sitting up. o Gastrointestinal: Denies nausea, vomiting, diarrhea, abdominal pain, unusual flatus, belching. Last bowel movement was yesterday, soft, brown, and without obvious blood. o Genitourinary: Urinary tract infection (UTI) 6 months ago treated with cranberry juice, irregular menstrual cycles, sexually active single partner without protection, denies prior pregnancies or sexually transmitted dis-eases. Currently denies dysuria, vaginal discharge. Last menstrual period "a while ago—not sure when." o Musculoskeletal: Denies leg pain, recent trauma, or lesions. Denies numbness in extremities. o Skin: Notes recent left leg redness from ankle to knee, denies recent bug bites, rashes, or trauma or abnormal bruising. o Hematological: Denies blood clotting abnormalities, infections, cancer. HIV negative single test after divorce 3 years ago. o Neurological: Denies syncope, dizziness, weakness, numbness, paresthesias, slurred speech, sleepiness, seizures, memory loss. o Endocrine: Denies diabetes, thyroid disorder, hormone therapy. o Mental health: Denies ever having suicidal ideation, mania, depression, hallucinations, delusions. Physical Exam o Vital Signs: Temperature 99°F oral, heart rate 107 beats per minute, respiratory rate 26 breaths per minute, blood pressure 146/92mm Hg. o Weight: 250lb, and body mass index is 44.3. height 5’6â€, o Bedside monitor: Pulse oximeter 96% on 100% nonrebreather, cardiac monitor—sinus tachycardia (107 beats per minute) without ectopy or ST-segment changes. o Constitutional: 35 year old African American female, well developed, obese, hair matted, clothing worn, communicates with few sentences, occasionally making eye contact, in moderate distress. Appears more stressed now than during initial survey. o HEENT: Pupils equal, round, reactive to light and accommodation, 3 mm. Sclera clear without lid crusting. Maxillary sinus dullness and tender to palpation and percussion. Nasal membranes pale. Tympanic membranes clear bilaterally, no fluid noted, normal color, no exudates. Posterior pharynx without erythema or exudate. o Cardiovascular: Point of maximal impulse fifth intercostal space midclavicular line, without gallops, murmur, rub, or click. S2 split with pulmonic increased loudness. Jugular venous distension (JVD) 9cm at 45° head of bed elevation. o Pulmonary: Symmetric breathing pattern with slight sternocleidomastoid muscle use. Using short answers/sentences. Percussion reveals bilateral dullness in lower bases. Breath sounds bilaterally diminished, technically difficult examination due to body habitus. o Gastrointestinal: Bowel sounds present in all four quadrants. Liver span unable to assess due to body habitus. Negative abdominal tenderness, masses or nodes, bruits. o Musculoskeletal: Symmetrical, well developed with full range of motion of upper extremities and lower extremity range of motion limited by edema. No effusion, crepitus, or movement tenderness. Straight legs raise 70° bilaterally before pain limits movement. o Neurological: Alert and oriented X3, cranial nerves II-XII intact. Deep tendon reflexes 2+ bilaterally upper extremities but unable to elicit in lower extremities bilaterally. Upper and lower extremity sensory intact bilaterally. Logical thought process but somewhat sluggish in response to questions. Flat affect. o Extremities: Nonpitting edema right leg 2+ at ankles and 1 + at knee without erythema, hyperthermia, lesions. Nonpitting edema left leg 3+ ankles to mid-thigh, erythema from ankle to knee, hyperthermia, without lesions. Upper extremities without edema, erythema, movement impairment, pain, or lesions. o Integumentary: Good skin turgor, intact, without lesions. Left leg redness is uniform without rash or streaking from ankle to knee. No stasis dermatitis or other abnormal vascular patterns. o Lymphatic: No lymphadenopathy appreciated but limited by body habitus. Preliminary Imaging Studies and Diagnostic Results o Chest x-ray: No fluid, infiltrates or pneumothorax noted. Difficult interpretation due to body habitus. o EKG: Sinus tachycardia, no arrhythmias or ischemic changes. No cardiomegaly. o Doppler ultrasound: left femoral vein thrombus, right leg ultrasound negative for thrombus. o CTA: shows bilateral scattered small pulmonary emboli in both the main pulmonary arteries and the segmental branches. Laboratory Results o hCG: negative o CMP: normal with the exception of a serum carbon dioxide of 18 o CBC with differential: normal, no anemia, white blood cell count and bands within normal limits o Coagulation times: normal ABG on FiO2 1.0 nonrebreather mask: ABG Results Normal pH 7.30 7.35-7.45 PaCO2 30mm Hg 35-45 ÐСО3 18 mEq/L 22-26 PaO2 75 mm Hg >80 O2Sat 96% >98 Case Study Questions 1. What are the pertinent positives and the significant negatives of this case? 2. What are the key symptoms and findings in the history and physical examination of the patient? 3. Based on the initial presentation, what differential diagnoses would you consider, and why? 4. What additional labs/diagnostic testing or investigations would you recommend to further evaluate this patient's condition, and what information would these tests provide? 5. Considering the patient's history and preliminary test results, what is your primary diagnosis at this point, and what is the basis for this diagnosis? 6. What immediate interventions or treatments would you initiate based on the initial assessment and diagnosis? 7. Which aspects of the patient's medical history or current condition require urgent attention or monitoring? 8. How would you explain the possible complications or risks associated with the identified diagnosis to the patient? 9. What long-term management strategies or follow-up care would you recommend for this patient? 10. What national guidelines were used to complete this case study?

Paper For Above instruction

Introduction

The case of a 35-year-old African American woman presenting with bilateral leg swelling, erythema in her left leg, and signs of pulmonary embolism highlights critical concerns in adult gerontology critical care. Recognizing and managing thromboembolic events, especially deep vein thrombosis (DVT) and pulmonary embolism (PE), necessitates prompt assessment, diagnostic accuracy, and initiation of appropriate treatments. This paper explores the pertinent positives and negatives, differential diagnoses, diagnostic strategies, and management plans based on the comprehensive clinical presentation.

Analysis of Pertinent Positives and Negatives

Pertinent positives include the right leg nonpitting edema, left leg erythema and hyperthermia, jugular venous distension (JVD), bilateral scattered pulmonary emboli, and DVT confirmed by ultrasound in the left femoral vein. The patient's recent URI symptoms, increased respiratory effort, tachycardia, and hypoxemia are significant indicators of a possible thromboembolic event. Notably, the absence of fever, normal laboratory counts, and unremarkable chest x-ray are negatives, although the findings on CTA confirm emboli.

Pertinent negatives comprise lack of chest pain, no evidence of trauma, no prior history of thromboembolism, no recent surgery, and no apparent source of infection that could complicate the presentation. The absence of purulent or systemic signs suggests that infection is less likely to be the primary cause of the swelling and respiratory distress.

Key Symptoms and Physical Findings

The patient's key symptoms include bilateral lower limb swelling, erythema and hyperthermia in the left leg, mild respiratory distress, and recent URI symptoms. Physical findings of note are jugular venous distension, decreased breath sounds with bilateral dullness, right leg nonpitting edema, and more severe edema with erythema and warmth in the left leg. Laboratory and imaging confirm DVT and PE, with physical signs pointing to right-sided heart strain and possible fluid overload.

Differential Diagnoses and Rationale

Based on initial presentation, differential diagnoses include:

• Deep vein thrombosis (DVT) with pulmonary embolism (PE): Confirmed by ultrasound and CTA, with classic signs of limb swelling, erythema, hyperthermia, and emboli in pulmonary arteries.
• Cellulitis or skin infection: Ruled out due to lack of localized warmth, tenderness, or systemic signs beyond erythema.
• Heart failure: Possible, given JVD and edema, but less supported due to absence of orthopnea or crackles on auscultation.
• Venous insufficiency or chronic edema: Unlikely due to sudden onset and associated PE.
• Other causes of edema such as nephrotic syndrome or liver disease: Less likely given normal labs and absence of other systemic signs.

Additional Diagnostic Tests and Rationale

Further testing includes:

• D-dimer assay: To evaluate for ongoing thrombosis, although in this case, it may already be confirmed by imaging.
• Venous Doppler ultrasound of the right leg: To assess for DVT in the opposite limb, especially given bilateral symptoms.
• ECHOCARDIOGRAPHY: To assess for right ventricular strain, indicating the severity of PE and cardiac impact.
• Repeat ABGs: To monitor gas exchange and hypoxemia severity.
• Additional labs: Including cardiac enzymes, BNP, renal function tests, and coagulation profile to guide management.

Primary Diagnosis and Its Basis

The primary diagnosis at this stage is bilateral pulmonary emboli secondary to deep vein thrombosis. The clinical signs of limb edema, erythema, hyperthermia, positive Doppler ultrasound, and CTA demonstrating emboli support this conclusion. The patient's immobility due to recent illness and obesity further predispose her to thromboembolism.

Immediate Interventions and Treatments

Initial management involves:

• Oxygen therapy: To improve hypoxemia, as evidenced by ABG and pulse oximetry.
• Anticoagulation: Initiate low molecular weight heparin (LMWH) or unfractionated heparin infusion to prevent clot propagation.
• Hemodynamic stabilization: Monitoring blood pressure, jugular venous distension, and signs of right heart failure.
• Positioning: Elevate legs to reduce edema but carefully monitor for embolic risk.

Urgent Aspects for Monitoring

Close observation of respiratory status, oxygenation, hemodynamics, and signs of expanding emboli are critical. Particular attention should be paid to jugular venous pressure, blood pressure, and heart rate to detect cardiac compromise.

Patient Education on Risks and Complications

The patient should be informed about risks associated with PE, including cardiac strain, hypothesized risk of recurrent thromboembolism, chronic pulmonary hypertension, and potential for sudden death. Emphasize the importance of adherence to anticoagulation therapy and recognition of symptoms indicating worsening condition.

Long-term Management Strategies

Long-term strategies include continued anticoagulation (typically 3-6 months or longer), lifestyle modifications such as weight loss, smoking cessation, and mobilization. Regular follow-up with hematology and cardiology, use of compression stockings, and patient education about signs of recurrent thrombosis are essential.

Guidelines Referenced

The management aligns with the American College of Chest Physicians (ACCP) Evidence-Based Clinical Practice Guidelines on Antithrombotic Therapy and the CHEST guidelines for VTE management (Kearon et al., 2016). These provide detailed recommendations for initial treatment, assessment of PE severity, and duration of anticoagulation therapy.

Conclusion

This case depicts a young woman with confirmed DVT and PE, emphasizing the importance of prompt diagnosis, aggressive stabilization, and long-term management to prevent recurrence and reduce morbidity and mortality. Integrating clinical findings with guideline-based interventions is crucial in complex adult gerontology critical care scenarios.

References

1. Kearon, C., Akl, E. A., Ornelas, J., et al. (2016). Antithrombotic Therapy for VTE Disease: CHEST Guideline and Expert Panel Report. Chest, 149(2), 315-352.
2. Di Nisio, M., Wichers, J., & Büller, H. R. (2018). Management of Venous Thromboembolism. New England Journal of Medicine, 378(21), 2012-2020.
3. Hull, R. D., & Raskob, G. (2017). Pulmonary embolism: diagnosis, management, and long-term outcome. The Lancet, 389(10078), 97-107.
4. Rali, M. R., & Wierzbicki, S. (2017). Acute pulmonary embolism: rapid diagnosis and initial management. Postgraduate Medical Journal, 93(1092), 245-249.
5. Patel, R., & Chatterjee, S. (2019). Deep vein thrombosis and pulmonary embolism: an overview. The Journal of Clinical & Experimental Cardiology, 10(6), 1-7.
6. Stein, P. D., & Beemath, A. (2018). Diagnostic approaches to pulmonary embolism. Chest, 154(3), 659-672.
7. Jaff, M. R., McMurtry, R., & Archer, S. (2019). Management of Massive and Submassive Pulmonary Embolism. European Heart Journal: Acute Cardiovascular Care, 8