Acute Hypoxic Respiratory Failure Case Study
The College of St. Scholastica 8710 Management I Case study 2 Chief Complaint: Acute hypoxemic respiratory failure Case Information: History of present illness: 72 year-old female presents to rural medical facility with reported progressive encephalopathy and subsequent hypoxia. On arrival to outlying facility she was noted to be saturating 79% on room air and obtunded. Due to severe altered mental status/obtunded and hypoxia patient was intubated with a size 8.0 ETT RSI medications 50mg rocuronium and 100mg ketamine and prepared for transfer. During transfer patient developed significantly worse hypoxia O2 sats in the 50s requiring bag valve mask 100% and increased PEEP 15 to obtain O2 saturations in the mid-80s. On arrival to the ICU Chest Xray and CT chest without contrast noted significant atelectasis of the left lung field and possible mucus impaction in the left bronchi. Emergent bronchoscopy was performed with findings of large amount of secretions in Left mainstem bronchus. Bronchial lavage and suction was completed and tests were obtained. Past medical history: COPD (FEV1/FVC ratio 60% FEV1 61% DLCO 54%), GERD, Wernicke’s encephalopathy, OSA, pulmonary nodules, depression, small fiber neuropathy, anorexia, essential tremor Past surgical history: hiatal hernia repair, nissen fundoplication 2019 Exposures: no recent travel, no pets, no recent exposure to sick contacts PTA Medications: Albuterol 2 puffs q4h prn for shortness of breath Folic acid 1mg PO daily Gabapentin 300mg TID Midodrine 2.5mg tid Rosuvastatin 20mg daily Citalopram 20mg daily Ipratropium-albuterol 0.5-.25mg/3ml q4h prn for shortness of breath or wheezing Omeperazole 20mg PO every morning, 60mg PO every evening Ondasetron 4mg PO q8h prn for nauseas or vomiting Lorazepam 1mg take 0.5 to 1 tab PO as needed for anxiety Mirtazapine 15mg PO daily at bedtime Family History: Noncontributory Allergies: Naproxen: Hives Codeine: abdominal pain Sulfamethoxazole-trimethoprim: dizziness ROS: Unable to obtain Social: Per family/chart: denies use of alcohol, illicit drugs, or vaping. Current everyday smoker 1pk/day for 40 years Vital Signs: wt: 51 kg, ht 5’7’’, T 97.6F, HR 112, BP 93/57, SpO2 95% RR 26 Physical Exam: General: chronically ill appearing, cachectic, intubated, sedated HEENT: orotracheal tube, orogastric tube CV: S1S2, sinus tachycardia, no murmur Pulm: barrel chest, diminished breath sounds Left lung field, CTA on right Abdomen: flat, soft, nondistended, active bowel sounds in all 4 quadrants Extremities: no edema Skin: No clubbing, cyanosis, rash, or lesions, scattered ecchymosis Neuro: sedated, pupils equal and reactive to light 3mm brisk, does not follow commands, withdraws from noxious stimuli in all extremities Labs: WBC HGB HCT MCV PLTS INR 17.8* 12.4 39.3 94.7 149 1.2* NA K CL CO2 BUN CREAT GLUC PHOS MAG PROTT CA CAION ALB BILIT ALKPH ALTSGPT AST 140 3.7 119* 12* 18 0.86 278* 5.0* 2.2 5.2* 7.6* 4.6 2.7* 0.5 61 63* 53* PCO2 PO2 HCO3 O2SAT pH 60* 186* 19* 99.3 7.22 Imaging: Prebronchoscopy Post bronchoscopy Questions: 1. What is differential diagnosis respiratory failure? What is your differential diagnosis for altered mental status? 2. What is your working diagnosis for altered mental status and respiratory failure? 3. What additional workup would you order to confirm your diagnosis or rule out your differentials and why? Additional labs, imaging, tests, procedures with justification? 4. What treatments would you order for this patient (i.e. medications, diet, follow up labs, activity, nursing orders, consults?) Case Information: Patient is extubated 24 hours after admission to ICU to 3L NC, weak cough, audible rhonchi which also improves over next several days. Bronchoscopy BAL reveals normal respiratory flora. Upon further history taking from husband and further medical records. S/p hiatal hernia repair and Nissen fundoplication in July 2019 patient has had a very poor appetite with unintentional weight loss approximately 50lbs since 2019 and was recently being evaluated for placement of peg tube due to poor appetite and nutritional deficiencies. Recently she was hospitalized and treated with IV thiamine x3 days for altered mental status secondary to Wernicke’s encephalopathy. She was discharged to a transitional care unit and then home 10 days later. Per husband patient required significant care at home over past two weeks due to incontinence, weakness, altered mental status and confusion. Additionally, she had been following with pulmonary medicine for several years for several pulmonary nodules specifically a density in the right upper lobe and right middle lobe. She also had a CT chest abdomen/pelvis and MRI abdomen which revealed possible cysts in her pancreas. Questions: 5. If you ordered antibiotics do you want to make any changes? Duration? 6. Would you order any further testing? Imaging? Consults? 7. What other issues related to long-term management are necessary to consider and discuss with the family? 8. What specific patient education would you want to provide prior to dismissal? Follow up? Prevention? Rationale.
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