Year Admitted Hospital Question & Answer Guide (With Explanation)
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Key Explanation
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Original Question
HPI Mr. J.R. is a 73-year-old man, who was admitted to the hospital with clinical manifestations of gastroenteritis and possible renal failure. The patient’s chief complaints are fever, nausea with vomiting and diarrhea for 48 hours, weakness, dizziness, and a bothersome metallic taste in the mouth. The patient is pale and sweaty. He had been well until two days ago, when he began to experience severe nausea several hours after eating two burritos for supper. The burritos had been ordered from a local fast-food restaurant. The nausea persisted and he vomited twice with some relief. As the evening progressed, he continued to feel “very bad” and took some Pepto-Bismol to help settle his stomach. Soon thereafter, he began to feel achy and warm. His temperature at the time was 100.5°F. He has continued to experience nausea, vomiting, and a fever. He has not been able to tolerate any solid foods or liquids. Since yesterday, he has had 5-6 watery bowel movements. He has not noticed any blood in the stools. His wife brought him to the ER because he was becoming weak and dizzy when he tried to stand up. His wife denies any recent travel, use of antibiotics, laxatives, or excessive caffeine, or that her husband has an eating disorder. PMH • HTN X 14 years • Post-AMI X 10 years • Heart failure X 8 years • No known renal disease or DM • Osteoarthritis X 5 years • DVT at age 61, treated with anticoagulants for 1 year FH • Father died at age 50 from AMI • Mother has type 2 DM • Has two brothers, both living, with no known medical problems • Has two sons without medical problems SH • Retired pharmacy professor who is living at home with his wife of 34 years • Denies use of alcohol, tobacco, and illicit drugs • Has 2 cups of coffee maximum daily ROS Was not performed as patient is acutely ill Meds • Digoxin 0.125 mg po QD • Furosemide 40 mg po QD • Enalapril 20 mg po QD (recently added to furosemide to manage HTN) • OTC acetaminophen 500 mg po PRN All • Sulfa drugs (anaphylaxis) • Molds (watery eyes and sneezing) Physical Examination and Laboratory Tests General The patient is a pale, diaphoretic, elderly Asian male in acute distress. The patient’s eyes appear sunken with dark circles around them. Arterial Blood Gas Results pH 7.35 PaO2 87 mm Hg PaCO2 29 mm Hg SaO2 95% Vital Signs BP 92/45 RR 30 WT 185 lbs P 115 T 101.3°F HT 5’11” Skin • Pale • Poor turgor • Warm to touch • Patient denies itching HEENT • PERRLA • No funduscopic abnormalities • EOMI • Conjunctiva pale • Non-erythematous TMs • Nose clear w/o exudates or lesions • Mucous membranes pale and dry • Tongue rugged • Slight erythema in throat Neck/LN • Supple • No JVD or HJR • No lymphadenopathy or thyromegaly • No carotid artery bruits Heart • Normal S1 and S2 • Faint S3 • No murmurs or friction rubs • Normal sinus rhythm Lungs No crackles bilaterally Abd • Diffuse tenderness • No guarding or rebound • Soft and non-distended with hyperactive bowel sounds • No HSM Genit/Rect • Prostate exam normal • Slightly heme-positive stool in the rectum • No grossly visible blood MS/Ext • Normal muscle strength bilaterally • No CCE • Peripheral pulses weak at 1+ bilaterally • Patient denies any muscle tenderness Neuro • A & O X 3 • CNs intact • Motor function—no focal weakness • Slightly decreased patellar reflex, otherwise normal reflexes • Normal coordination and gait Laboratory Blood Test Results Na 144 meq/L Cr 2.6 mg/dL Alb 4.3 g/dL PMNs 29% K 4.7 meq/L Glu, random 155 mg/dL Hb 13.9 g/dL Lymphs 66% Cl 111 meq/L Ca 9.1 mg/dL Hct 48% Monos 3% HCO3 19 meq/L Phos 4.1 mg/dL Plt 190,000/mm3 Eos 1% BUN 57 mg/dL Mg 2.8 mg/dL WBC 11,700/mm3 Basos 1% UA • Clear, pale yellow urine • Microscopy was negative for cells, casts, pigments, and crystals • SG 1.019 • (-) bacteria • (-) glucose • (-) protein • WBC 1/HPF with no eosinophils • RBC 1/HPF • Na concentration = 14 meq/L • Osmolality = 769 mOsm/kg H2O 1. Why do you expect that an ultrasound study of the patient’s urinary tract was not conducted? B. Which therapeutic measure should be considered “first and foremost” and may be very beneficial in reversing the signs of acute renal failure? C. Would dialysis be appropriate treatment for this patient at this time? D. Should sodium polystyrene sulfonate therapy be instituted in this patient? E. As an advanced practice nurse, how would you explain the condition to his wife? F. What kind of teaching would you provide to JR and his wife for their well-being?
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