MSN 5041: Adult Gerontology Advanced Critical Care Concepts for Intensivist in Acute Care

A 67-year-old African American male is transported via ambulance from a primary care clinic to

 

the nearest emergency room (ER) with a severely elevated blood pressure of 228/120

 

accompanied by confusion.

 

The emergency medical responders report that the patient has a long-standing history of

 

uncontrolled hypertension (HTN), type 2 diabetes mellitus (DM), and hypercholesterolemia. He

 

was seen by his primary care nurse practitioner (NP) who noted that the patient had an elevated

 

blood pressure of 230/120 associated with acute confusion. An ambulance was called to

 

transport the patient to the nearest ER.

 

History of Present Illness

 

The patient’s wife denies that the patient experienced weakness, paresis, or paralysis of

 

extremities, dysarthria, aphasia, or other signs that may indicate a stroke, but notes that the

 

patient started acting “strangely” at approximately 8pm the night before admission. This morning

 

he was confused about the day and year, and forgot many of the details of his daughter’s recent

 

wedding. She was concerned so she took him to the primary care office, where the NP called

 

911. She reports there is no recent history of trauma, falls, or substance abuse. She endorses that

 

the patient has hypertension and diabetes, as reported by the primary NP, and denies any history

 

of cancer or heart disease. She also reports that he stopped taking his blood pressure medications

 

approximately 6 months ago because they caused excessive fatigue. She is unsure if he is taking

 

his other prescribed medications.

 

Past Medical History: HTN, DM, Type II, High cholesterol

 

Past Surgical History: Per wife and the EMR, patient has never had surgery

 

Social History: Patient’s wife reports he has never smoked, does not drink, does not use drugs

 

Medications:

 

• No known allergies

 

• Lipitor 10mg PO daily

 

• Metformin 500mg PO BID

 

• Per EMR: He is prescribed Amlodipine 10mg PO daily and Toprol 50mg PO daily, but

 

has not filled his prescriptions for the last 6 months

 

General Survey The patient’s vital signs on admission to the ER are:

 

BP 228/116 mmHg

 

HR: 78 beats per minute, normal sinus rhythm on the monitor

 

RR: 18 breaths/min

 

O2 sats: 96% on room air

 

He is lethargic but easily arousable, disoriented to time and place, and therefore unable to give a

 

reliable history. Data is gathered from his wife and the electronic medical record (EMR).

 

Review of Systems

 

The patient is unable to answer all of the questions; some of the information is obtained from the

 

patient’s wife.

 

Constitutional: denies fever, chills

 

Cardiovascular: denies chest pain, chest pressure, SOB, palpitations

 

Pulmonary: denies SIB

 

GI: denies abdominal discomfort, unable to determine last bowel movement

 

GU: denies burning with urination

 

Musculoskeletal: denies pain of extremities

 

Neurological: the patient is unable to provide a timeline as to the onset of confusion; per wife the

 

patient started acting “strangely” after dinner – “quiet, non-communicative, not answering

 

questions – said he did not feel well, but would not elaborate”. This morning his wife was

 

concerned when he appeared dazed and confused. He was disoriented to day and time. Wife

 

reports acute changes to short – and -long term memory.

 

Endocrine: denies thirst, excessive urination or excessive hunger, does not check blood glucose

 

at home.

 

Physical Examination

 

Vital signs

 

Repeat blood pressure is 200/120 mmHg in both right and left arms

 

Temp 36.0 C oral

 

HR 78 beats per minute

 

RR 16 breaths per minute

 

O2 sats 95% on room air

 

Weight 90 kg

 

Height 5’10”

 

BMI 28.1

 

Constitutional: Obese male, appears stated age, lethargic, disoriented to time and place, oriented

 

to person, arouses easily, able to answer simple questions with a “yes” or “no”.

 

HEENT: Normocephalic, anicteric, fundoscopic examination reveals exudates and cotton wool

 

spots, consistent with grade III retinopathy, no carotid bruits, no thyromegaly, or thyroid

 

nodules.

 

Cardiovascular: S1, S2, no murmurs, no gallops, no rubs, +displaced PMI. Pulses are present

 

bilaterally +2+2 right and left dorsalis pedis and posterior tibial pulses.

 

Pulmonary: Respirations are even and unlabored, breath sounds are clear and equal throughout.

 

Gastrointestinal: Normoactive bowel sounds, abdomen is soft, non-tender, non-distended, no

 

hepatosplenomegaly, + left epigastric abdominal bruit – systolic diastolic bruit.

 

Skin: Warm and dry, no rashes or lesions noted.

 

Musculoskeletal: Nontender spine; +systolic-diastolic bruit – located at the mid to lower left of

 

the spine.

 

Neurological: Limited neurological examination due to the patient’s inability to follow

 

commands. Cranial nerves II-XII intact, however, unable to examine extraocular movements

 

due to the patient being unable to follow commands; otherwise grossly non-focal, able to move

 

both arms and legs; no facial asymmetry, no dysarthria.

 

Preliminary Diagnostic Results

 

12-lead ECG reveals NSR of 78 beats per minute; PR interval 0.14, QRS interval 0.06; QT

 

interval 0.40 with left ventricular hypertrophy.

 

CXR demonstrates borderline cardiac enlargement; negative for a widened mediastinum.

 

NECT: negative for bleeding; diffuse white matter changes consistent with cerebral

 

encephalopathy.

 

Laboratory Results

 

Today One Year Ago Troponin 0.01 mg/mL

 

Na 140 mEq/L 136

 

K 4.4 mEq/L 4.2

 

Cl 105 mEq/L 107

 

CO2 24 mEq/L 21

 

Total cholesterol 200 mg/dL 261

 

LDL 139 mg/dL 156

 

HDL 32 mg/dL 25

 

Triglycerides 300 mg/dL 402

 

BUN 40 mg/dL 23

 

Creatinine 2.5 mg/dL 1.0

 

WBC 6,900 cells/uL 7,600

 

Hbg 12.7 g/dL 13.8

 

Hct 35.5% 38.5

 

Glucose 92mg/dL 105

 

HgbA1c 8.5 7.0

 

GFR 36 cc/min 87

 

Urinalysis: specific gravity 1.020, pH 5.0, color clear, protein 100 mg/dL,

 

leukocyte esterase negative, nitrate negative, ketones negative, red blood cells

 

negative.

 

Toxicology screen: negative

 

Case Study Questions

 

1. What are the pertinent positive of this case?

 

2. What are the significant negatives of this case?

 

3. What laboratory and diagnostic testing should be ordered? Use national guidelines to support

 

your responses.

 

4. Provide a case analysis and formulate your diagnosis and treatment plan. Provide a minimum

 

of 3 differential diagnoses and explain each. Use national guidelines to support your responses.

 

5. Follow APA, 7th edition guidelines.