This activity, your task is to meticulously analyze the provided case study, ensuring to identify both pertinent positives and significant negatives. Additionally, consider su

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 × 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. Describes work as "usual stress" Manages stress with daily meditation and journaling. Satisfed with current male partner relationship.

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 5’6”,

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 midcla-vicular 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-XIl intact. Deep tendon reflexes 2+ bilaterally upper extremities but unable to elicit in lower extremities bilaterally.

Upper and lower extremity sensory intact bilater-ally. Logical thought process but somewhat sluggish in response to ques-tions. 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 НСО3 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?