Case Study Year Explained for Students (Easy Guide)
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Key Explanation
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Original Question
Case study Mrs. Tam, Yan is a 72-year-old lady presenting to the emergency department at 0400hrs with worsening shortness of breath. Family reports SPO2-82% on room air at home and functional decline over the last three to four weeks. She also developed wheeze and right sided pleuritic chest pain this morning. Community nurse attended home today for review of bilateral lower limb edema, blisters and weeping. Vomited x1, ongoing nausea. Has history of non-compliance with medication and adherence to fluid restriction. Family reports previously was able to walk from chair to toilet with assistance and has been unable to do so for the last three weeks. Past History Hypertension, Inferior Myocardial Infarction in 2020, Heart Failure, non-ischemic Cardiomyopathy, Permanent Pacemaker inserted 2021, DM Type II, Hypercholesteremia, GORD, Osteoarthritis, Cataracts. On 1.2 L fluid restriction; Echocardiogram results in 2021- systolic dysfunction, mild mitral valve regurgitation, dilated left atrium and ejection fraction (EF) 33%. Current medications: Furosemide 40mg OD, Captopril 6.25 mg TiD, Digoxin 0.125 mg BD, Atorvastatin 20 mg nocte, Metformin 500mg TiD, Nexium 40 mg BD. Nursing Assessment A. Clear, speaking in short sentences B. RR 28 bpm, SpO2 90% 2 L O2, bilateral crackles, diffuse wheeze anteriorly and posteriorly, using accessory muscles, intermittent productive cough with pink frothy sputum. C. HR 120 bpm, peripherally cold, centrally warm, BP 91/55 mmHg, capillary refill 4 sec D. GCS 14 (E4V4M6) Not oriented to time, place or person. PEARL E. Patient looks distressed, diaphoretic, right JVP distension++, bilateral pedal pitting edema 2+, sacral edema ++, bilateral lower limbs edema, blisters, weeping ++ (bandage intact, not too tight, can fit fingers between leg and dressing) F. No IV fluids in progress, NBM for now G. BGL 14.0mmol/L. Plan • Continuous cardiac monitoring • 12 lead ECG • Arterial Blood Gas analysis • Blood pathology order • Troponin I High Sensitivity • Chest X-Ray • Insert IVC right hand • Furosemide 40mg IV Stat • Salbutamol Nebuliser burst (3 doses of 5mg Salbutamol nebules within 20 minutes) • For likely Non-Invasive Ventilation if dyspnoea persists • Digoxin IV 600mcg loading dose • Echocardiogram • ICU review • Obtain daily weights • Dietary salt restriction – dietician review Results of Investigations: Chest x- ray: Left ventricular hypertrophy, interstitial edema noted by Kerley B lines in the costophrenic angle, patchy infiltrates bibasally. ECG: File attached Why is she vomiting Why does she need daily weights Why she has developed wheezes Why she has sacral edema Why she needs supplemental oxygen
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