Signature Assignment – CASE STUDY FOR CASE MAP
SITUATION:
Jessie Diaz, a descendant from Mexico, has a significant medical history of cardiopulmonary
disease. Jessie was transported by ambulance to the emergency department for increasing
shortness of breath, worsening productive cough of thick pink mucus, and edema of the lower
extremities that began 19 days ago.
Per protocol, vital signs and continuous cardiac monitoring were initiated upon arrival at the
emergency department. Blood work for arterial blood gases has resulted.
Successfully intubated (#6 Shiley) and vented: FiO2 is 65%, PEEP 5cmH2O, respiratory rate 22
breaths/min, and tidal volume 6-8 mL/kg.
Vital Signs
Time 1400
Temp 99.14 F (37.2 C)
P 126, irregular
RR 38
B/P 102/50
MAP 67
Pulse oximeter 76% RA
Laboratory Report
Lab Results Reference range
ABG pH 7.31 7.35-7.45
ABG PaO2 64 80-100 mmHg
ABG PC02 52 35-45 mmHg
ABG HC03 19 22-26 mEq/L
BACKGROUND:
Social History:
Jessie has a 38-pack/year history of smoking and drinks wine socially. The family with Jessie
denies substance use. * Jessie’s sole source of income is social security.
Medical History:
Bronchitis with Pneumonia (2008, 2018)
• Jessie required a tracheostomy for ventilation management in 2018; the initial trach was
downsized and removed to health while participating in acute rehab.
DVT (2008, 2018)
Diabetes Mellitus
Atherosclerosis and hyperlipidemia
Coronary Artery Disease with non-STEMI MI (2010)
Surgical History:
Internal fixation repair of ankle fracture following MVA 15 years ago
Tracheostomy (2018)
Medications
Empagliflozin 10 mg PO daily
Sitagliptin / metformin 50-1000 mg PO daily
Valsartan 160 mg PO daily
Clopidogrel 75 mg PO daily
Atorvastatin 20 mg PO daily at bedtime
Advair Discus twice daily
Assessment:
Day of Admission:
Jessies is admitted to the intensive care unit (ICU) with Acute Heart Failure and a new onset of
Atrial Fibrillation with Rapid Ventricular Response (RVR). A Dexmedetomidine drip was started
for sedation; Amiodarone for drip for atrial fibrillation; Heparin for DVT prophylaxis; and
Pantoprazole for gastric ulcer prophylaxis.
Day 2 – 1400
Cardiac monitoring continued with normal sinus rhythm with occasional PVC and PACs. A nasal
swab for MRSA is positive, and contact precautions started. Crackles were noted in the posterior
lung bases, and increased edema in the lower and upper extremities. Furosemide drip was
initiated with a goal of an hourly negative fluid balance of 100 mL. Tube feedings started at 20
mL/hr and are to be increased by 20 mL every 6 hours to a goal of 55 mL/hr. The
dexmedetomidine drip was discontinued. Intermittent Midazolam and Hydromorphone, PRN
administered.
Day 3 – 1000
SBT unsuccessful. A chest tube was inserted under local anesthesia, connected to a water seal
and negative wall suction, and continued on the vent. Chest XR results show a 15%pneumothorx
in the apex of the right lung.
Day 4 – 1130
Enteral nutrition continued, now at goal. Clients remain in NSR x3 days. The Heparin drip was
discontinued, and subcutaneous Heparin daily for DVT prophylaxis started. The Furosemide drip
was stopped, and administered Furosemide 80 mg was every 12 hours. The chest tube remains
intact with bubbling in the water seal chamber. Blood sugars are elevated; started on insulin
sliding scale and insulin drip per protocol.
Day 5 – 1800
SBT was successful, and the client was changed to a trach collar, #4 Shiley. Insulin drip was
discontinued and started on 18 units of Lantus at bedtime with continued sliding scale coverage.
Chest tube downgraded, removed from wall suction. Hourly bedside rounds continued. The
client is upright in bed with feet hanging from the side in a seated position.
Day 6 – 1200
Lung fields clear anterior/posteriorly. Chest tube removed, started on Warfarin 3 mg. The client
transferred to Surgical Step Down. Enteral nutrition continued. Chest tube intact, no blood noted
in the drainage.
Day 7 0930
During the handoff report, the client complained of right leg pain; MD was made aware, and a
venous doppler was ordered, resulting in a DVT at the popliteal vessel. Weight-based Heparin
drip started. Sitagliptin/Metformin 50-1000mg PO was ordered with sliding scale insulin
coverage. Lung fields remain clear anteriorly/posteriorly. The client will be evaluated by PT and
plan for discharge to rehab in two days. `
Day 10
The client will be discharged to subacute rehab on home medications. Discharge teaching
provided; the client will continue on Warfarin 3mg PO daily with weekly INRs. The client was
advised to follow up with a primary healthcare provider.
LAB RESULTS
Lab Result ICU Admission
Day 2
0630
Day 4
0630
Day 6
0630
Day 10
0630
Sodium 139 mEq/L 139 mEq/L 130 mEq/L 132 mEq/L 135 mEq/L
Potassium 4.6 mEq/L 3.6 mEq/L
3.2 repeated to
4.1 mEq/L 4.2 mEq/L 4.0 mEq/L
Chloride 97 mmol/L 99 mmol/L 98 mmol/L 99 mmol/L 98 mmol/L
CO2 27 mmol/L 34mmol/L 32 mmol/L 33 mmol/L 35 mmol/L
Calcium 8.5 mg/dL 7.4 mg/dL 8.7 mg/dL 8.2 mg/dL
Phosphorus 4.3 mg/dL 3.6 mg/dL
3.2 mg/dL
repeated 3.7 mg/dL
Glucose 235 mg/dL 198 mg/dL 225 mg/dL 178 mg/dL 152 mg/dL
BUN 34 mg/dL 42 mg/dL 48 mg/dL 35 mg/dL 33 mg/dL
Creatinine 1.4 mg/dL 1.6 mg/dL 1.7 mg/dL 1.5 mg/dL 1.4 mg/dL
Total Cholesterol 230 mg/dL 218 mg/dL
LDL Total 196 mg/dL 186 mg/dL
HDL 44 mg/dL 45 mg/dL
ALT 28 U/L
AST 31 U/L
Troponin I 2.4 ng/mL 0.9 ng/mL
NT-proBNP 242 pg/mL
WBC 15,100/mm3% 17,400/mm3% 19.8/ mm3% 14.1/ mm3% 10.2/ mm3%
Hgb/Hct 8.7/26.2
Platelets 141/mm3 133/mm3 114/mm3 128/mm3 142/mm3
PTT 62 sec 38 sec 31 sec
PT/INR 15 sec/1.2 14 sec/1.4 32 sec/2.4
Chest X-ray RUL infiltrate
