Ella is a 62-year-old white female that lives at home alone
Ella is a 62-year-old white female that lives at home alone. Her daughter has brought her to the emergency room with acute onset shortness of breath. Ella’s breathing issues began two days ago and have been getting progressively worse. Ella’s daughter states they have attempted to relieve the symptoms with cough medicines and humidifiers, but nothing has helped.
When asked about her history, Ella states she had similar symptoms about a year ago with an acute, chronic obstructive pulmonary disease (COPD) exacerbation requiring hospitalization.
Ella uses BiPAP ventilatory support at night when sleeping to assist with her COPD. She’s requested to use BiPAP in the emergency room to assist with the shortness of breath. Ella is also fatigued and feels this will help her sleep.
Ella’s current medications include fluticasone-vilanterol 100-25 mcg inhaled daily; hydralazine 50 mg by mouth, 3 times per day; hydrochlorothiazide 25 mg by mouth daily; albuterol-ipratropium inhaled every 4 hours PRN; levothyroxine 175 mcg by mouth daily; metformin 500 mg by mouth twice per day; nebivolol 5 mg by mouth daily; aspirin 81 mg by mouth daily; vitamin D3 1000 units by mouth daily; clopidogrel 75 mg by mouth daily; isosorbide mononitrate 60 mg by mouth daily; and rosuvastatin 40 mg by mouth daily.
When conducting your initial assessment, Ella denies having a fever, cough, wheezing, sputum production, chest pain, palpitations, pressure, abdominal pain, abdominal distension, nausea, vomiting, or diarrhea. Ella states the difficulty in breathing is occurring while she is sitting at rest.
Ella’s daughter informs you Ella has been forgetful and seems fatigued. She also notes that her mom feels chilled and is wrapped in blankets at all times, even when it is warm outside. In addition, you learn Ella has increased urinary frequency and incontinence. Ella also has swelling in her bilateral lower extremities that is a new symptom and worsening.
Ella’s daughter is extremely concerned because her mom has not left her bed for several days, except to use the restroom. Ella’s daughter reports her mother complains of feeling weak, tired, and short of breath for the past two days.
The initial physical exam of Ella reveals a temperature of 97.3 Fahrenheit, heart rate of 74 bpm, respiratory rate of 24, and blood pressure of 104/54. Ella is 5’4″ and weighs 130 pounds. Her BMI is 22.3, and her O2 saturation level is 90 percent.
You visually identify that Ella is thin and appears very ill. She is does not appear in any distress while wearing the BiPAP. She also has four blankets over her while lying on the hospital bed.
When conducting a HEENT exam, you notice that the head is normocephalic and atraumatic. The mouth has moist mucous members, and the throat is pink and moist. You also notice that Ella’s tongue has macroglossia.
When examining Ella’s eyes, you identify that conjunctiva and EOM are normal. Her pupils are equal, round, and reactive to light. Ella also has no scleral icterus, but does have swelling around the eyes.
Ella’s neck is supple. There is no jugular vein distention, masses or surgical scarring.
During your initial assessment you assess Ella’s cardiovascular system. You identify a normal heart rate, regular rhythm, and normal heart sounds with no murmurs. When assessing the swelling in the bilateral lower extremities, you reveal grade 2 pitting. You also locate strong pulses in all extremities.
Your pulmonary evaluation detects tachypnea, wheezing, bilateral rhonchi, and decreased air movement bilaterally.
When questioning Ella, you notice she is barely able to complete a sentence due to shortness of breath.
Ella’s abdomen is soft with no distension or tenderness. There are also normal bowel sounds. Ella’s skin appears very dry. You note that Ella is alert, awake and able to protect her airway. She is able to move all her extremities and has not lost sensation in any areas.
You order a CBC for Ella to establish if an infectious or anemic source is present. The CBC analysis is largely unremarkable.
You also order a CMP to review her electrolyte balance and renal function. In addition, you order creatinine kinase and troponin I to evaluate the presence of myocardial infarction or rhabdomyolysis. You order a brain natriuretic peptide test to measure the levels of BNP protein in the blood.
The CMP analysis shows elevated levels of creatinine. Ella has a creatinine level of 1.81 and the baseline is 1.08. The Estimated Glomerular Filtration Rate (eGFR) is 28 and the calcium level is elevated to 10.2. However, when corrected for albumin, the value is 9.8 mg/dL. Alkaline phosphatase, AST, and ALT measurements show signs of mild transaminitis, which could be due to liver congestion from volume overload.
You order diagnostic exams for arterial blood gas to determine the PO2 for hypoxia and any major acid-base derangement. Ella has an initial arterial blood gas with pH 7.491, PCO2 27.6, PO2 53.6, HCO3 20.6, and oxygen saturation 90% on room air.
You’d also like Ella to get an EKG and chest x-ray to help determine the cause of her shortness of breath. An EKG on Ella shows normal sinus rhythm with non-specific ST changes in inferior leads. There is also decreased voltage in leads I, III, aVR, aVL, aVF.
A chest x-ray identifies bibasilar airspace disease that may represent alveolar edema. Cardiomegaly and prominent interstitial markings are also noted. The x-ray also shows bilateral pleural effusions. The radiologist reports radiographic changes of congestive failure with bilateral pleural effusions that are greater on the left.
Since it is winter and influenza is rampant, you also order a rapid influenza test. The influenza A and B test given to Ella is negative.
You admit Ella for observation. On the second day her shortness of breath is not improving. Ella seems more confused and has a difficult time maintaining alertness. Ella’s husband reveals that she is not very compliant with taking her medications. He reports that she doesn’t feel she needs all the medications prescribed.
A repeat of the arterial blood gas on BiPAP ventilation shows pH 7.397, PCO2 35.3, PO2 72.4, HCO3 21.2, and oxygen saturation 90% on 2 L supplemental oxygen.
You also order a CT chest scan without contrast to evaluate the left hemithorax, especially the retrocardiac area. The CT scan shows tiny bilateral pleural effusions and pericardial effusion. It also reveals coronary artery calcification and some left lung base atelectasis with minimal airspace disease.
You order an echocardiogram. It shows that the left ventricular systolic function is normal, with the left ventricular cavity borderline dilated. The pericardial fluid is collected laterally primarily posteriorly. The echocardiogram reveals a subtle, early hemodynamic effect of the pericardial fluid on the right-sided chambers by way of an early diastolic collapse of the RA/RV and delayed RV expansion until late diastole. The estimated ejection fraction appears to be in the range of 66% to 70%. The left ventricular cavity is borderline dilated. The aortic valve is abnormal in structure and exhibits sclerosis. In addition, the mitral valve is abnormal in structure. The echocardiogram shows mild mitral annular calcification and bilateral thickening. It also shows trace mitral valve regurgitation.
Collepals.com Plagiarism Free Papers
Are you looking for custom essay writing service or even dissertation writing services? Just request for our write my paper service, and we'll match you with the best essay writer in your subject! With an exceptional team of professional academic experts in a wide range of subjects, we can guarantee you an unrivaled quality of custom-written papers.
Get ZERO PLAGIARISM, HUMAN WRITTEN ESSAYS
Why Hire Collepals.com writers to do your paper?
Quality- We are experienced and have access to ample research materials.
We write plagiarism Free Content
Confidential- We never share or sell your personal information to third parties.
Support-Chat with us today! We are always waiting to answer all your questions.
