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Manifestation are correctly identified

PATHO CASE STUDY 3-DIRECTIONS-RUBIC This week’s case-study will introduce concepts related to respiratory disorders and shock. Read the scenario and thoroughly complete the questions. Some of the answers will be short answers and may not require a lot of details. For example: What is the most common organism to cause a hospital acquired infection? The answer is pseudomonas aeruginosa. Answers to questions that relate to the pathogenesis of a disease must include specific details on the process. For example: How does hypoxia lead to cellular injury? Simply writing that a lack of blood flow causes a lack of oxygen available to the cell and the cell cannot function without oxygen is not sufficient. This type of response is NOT reflective of an advanced understanding of the concept or graduate level work. This answer should discuss the cascade of events leading to the lack of oxygen and how it specifically impairs cellular function. All answers to these types of questions should address the effects at the cellular level, then the effects on the organ and then the body as a whole. Additionally, describing the normal anatomical and/or physiologic processes underlying the pathogenesis will be necessary to thoroughly answer the question. It is very likely that you will need to reference multiple sources to answer the questions thoroughly. Your textbook will not necessarily have all the answers. Only professional sources may be used to complete the assignment. These include textbooks, primary and secondary journal articles from peer reviewed journals, government and university websites, and publications from professional societies who establish disease management guidelines and recommendations. Sources such as Wikipedia or other generic websites are not considered professional references and should not be used to complete the case studies. Submit your answers in blackboard by the due date. The use of APA citations in the written text is required. Additionally, you will need to provide a list of references at the end of your paper. This is considered a professional writing assignment and you will be graded on grammar and spelling. A case study submitted after the due date will not be accepted for a grade or reviewed and will be assigned a grade of zero. You are expected to synthesize your readings and answer the questions. Plagiarism is prohibited. Copying your answers from your textbooks, journal articles, any website or any source is considered plagiarism. All of your work is to be in your own words, paraphrased and referenced accordingly. Any assignment determined to have been plagiarized will be given a zero and the student reported for academic dishonesty. Using quoted sentences is not an acceptable manner in which to complete any assignment in this course and does not reflect synthesis of the material. Consequently, the use of quoted sentences will result in a point deduction up to and including a zero. CASE STUDY: REASON FOR CONSULTATION: Desaturation to 64% on room air one hour ago with associated shortness of breath. HISTORY OF PRESENT ILLNESS: Mrs. X is a 73-year-old Caucasian female who was admitted to the general surgery service three days ago for a leaking j-tube which was surgically replaced two days ago. This morning at 07:30, the RN reported that the patient was sleeping and doing fine. Then the CNA made rounds at 09:00 and Mrs. X was found to be mildly dyspneic. Vital signs were checked at that time and were as follows: temperature 38.6oC, pulse 120, respirations 20, blood pressure 138/38. O2 sat was 64% on room air. The general surgeon was notified by the nursing staff of the hypoxia. An order for a chest x-ray and oxygen therapy were given to the RN. The O2 sat is maintaining at 91-92% on 4L NC. The patient was seen and examined at 10:10 a.m. She reported that she has had mild   Dyspnea 

for two days that has progressively gotten worse. She does not use oxygen at home. Her respiratory rate at the time of this visit was 20 and she feels short of breath. She has felt this way in the past when she had pneumonia. She is currently undergoing radiation treatment for laryngeal cancer and the last treatment was one to two weeks ago. She reported that she has two to three treatments left. She denied any chest pain or previous history of CHF. Review of her vital signs showed that she had been having intermittent fevers since yesterday morning. Of note, she was admitted to the hospital three weeks ago for an atrial fibrillation with RVR for which she was cardioverted and has not had any further problems. The cardiologist at that time said that she did not need any anticoagulation unless she reverted back into A-fib. REVIEW OF SYSTEMS: Constitutional: Negative for diaphoresis and chills. Positive for fever and fatigue. HEENT: Negative for hearing loss, ear pain, nose bleeds, and tinnitus. Positive for throat pain secondary to her laryngeal cancer. Eyes: Negative for blurred vision, double vision, photophobia, discharge and redness. Respiratory: Positive for cough and shortness of breath. Negative for hemoptysis and wheezing. Cardiovascular: Negative for chest pain, palpitations, orthopnea, leg swelling and PND. Gastrointestinal: Negative for heartburn, nausea, vomiting, abdominal pain, diarrhea, constipation, blood in stool and melena. Genitourinary: Negative for dysuria, urgency, frequency, hematuria and flank pain. Musculoskeletal: Negative for myalgias, back pain and falls. Skin: Negative for itching and rash. Neurological: Negative for dizziness, tingling, tremors, sensory change and speech changes. Endocrine/hematologic/allergies: Negative for environmental allergies or polydipsia. Does not bruise or bleed easily. Psychiatric: Negative for depression, hallucinations and memory loss. PAST MEDICAL HISTORY: 1. Diabetes mellitus that was diagnosed 12 years ago with neuropathy. This resolved after gastric bypass surgery, which she had approximately three years ago. 2. Laryngeal cancer 3. Hypertension 4. Hypercholesterolemia 5. Pneumonia 6. Arthritis 7. Hypothyroidism 8. Atrial fibrillation 9. Acute renal failure 10. Chronic kidney disease, stage IV – 4 months ago a renal biopsy was completed, which showed focal acute tubular necrosis and patchy tubular atrophy, moderate to severe interstitial fibrosis with patchy acute and chronic interstitial nephritis, normal cellular glomeruli with no white microscopic evidence of a primary glomerulopathy. Baseline creatinine is 1.9. 11. Peptic ulcer disease 12. Skin cancer 13. Anemia 14. Osteoporosis PAST SURGICAL HISTORY: 1. Gastric bypass three years ago 2. Closure of mesenteric defect 3. Radical neck resection one year ago. FAMILY HISTORY: 1. Mother had diabetes diagnosed at age 55 and high blood pressure. Deceased. 2. Father had heart disease diagnosed at age 60. Deceased. 3. She had a sister with diabetes, thyroid disease, CKD, on dialysis, with unknown etiology. SOCIAL HISTORY: She denies any smoking or alcohol use. She denies any drug use. MEDICATIONS: 1. Calcitriol 0.5 mcg PO every other day 2. Vitamin B12 2500 mcg sublingual every Monday and Thursday 3. Docusate sodium 100 mg PO BID 4. Fentanyl patch 100 mcg every 72 hours 5. Gabapentin 800 mg PO BID 6. Levothyroxine 50 mcg daily 7. Multivitamin 1 PO Daily 8. Oxybutynin 5 mg PO BID 9. Hydrocodone 5/325 1-2 tablets every six hours PRN pain ALLERGIES: SHE IS ALLERGIC TO CIPRO, WHICH CAUSES URTICARIA AND HIVES, CONTRAST DYE, HONEY AND BEE VENOM, ADHESIVE, AND SULFAS, WHICH CAUSE HIVES. PHYSICAL EXAMINATION: Vital signs: 38.6oC, 120, 20, 138/38, 64% on room air. She is maintaining O2 sat of 91 to 92 on 4 liters nasal cannula. Constitutional: She is somnolent. Oriented to person and place. Appears ill and mildly dyspneic. Head: Normocephalic and atraumatic. Nose: Midline, right and left maxillary and frontal sinuses are non-tender bilaterally. Oropharynx: Clear and moist. No uvula swelling or exudate noted. Eyes: Conjunctivae, EOM and lids are normal. PERL. Right and left eyes are without drainage or nystagmus. No scleral icterus. Neck: Normal range of motion and phonation. Neck is supple. No JVD. No tracheal deviation present. No thyromegaly or thyroid nodules. No cervical lymphadenopathy noted bilaterally. Cardiovascular: Regular rhythm, rapid rate, S1 and S2 without murmur or gallop. Brachial, radial, dorsalis pedis, and posterior tibial are 2+/4+ bilaterally. Chest: Respirations are regular and even with mild dyspnea. Lungs are coarse and with some rales in the posterior bases. Abdomen: Soft. Bowel sounds are active, non-tender, no masses noted. No hepatosplenomegaly noted. No peritoneal signs. Musculoskeletal: Full range of motion of the bilateral shoulders, wrists, elbows. Neurologic: Somnolent. Cranial nerves II-XII are intact. Skin: Warm and dry. Psychiatric: Mood and affect are normal. Calm and cooperative. Behavior, judgment is intact. LABORATORIES AND DIAGNOSTICS: WBC 7.2, Neutrophil 63% Creatinine 2.0, BUN 45, Na 144, Potassium 4.4 BNP 242 Lactate 1.0 All other labs are unremarkable. Chest x-ray: Right lower lobe infiltrate EKG: NSR, no ST or T wave changes One hour after having seen Mrs. X, you get a call from the RN to report that her BP is now 75/40, pulse is 140, RR is 34 and dyspneic, temperature is 39.6oC and she is minimally responsive. Mrs. X is transferred to the MICU. Upon re-evaluation of Mrs. X, you note that she is obtunded, struggling to breathe, using accessory muscles, and O2sats are 85% on a non-rebreather. She is intubated and placed on a ventilator. A central line is placed and confirmation obtained via CXR. A foley is placed and fluid resuscitation has begun. WBC 20,000 Hgb 12 HCT 36 Platelets 98,000 Na 148 Chloride 110 Potassium 5.6 Glucose 190 Creatinine 3.0 BUN 68 Albumin 3.0 Anion Gap 21 Lactate 5.2 Procalcitonin 15, INR is 1.0, aPTT 23 ABG (prior to intubation) pH 7.28, PCO2 36, HCO3 17 EKG: Atrial Fibrillation with RVR at 156 CVP 3 cmH2O Answer the following questions. 1. What are four plausible, pulmonary, differential diagnoses for Mrs. X’s hypoxemia that are specific to her clinical scenario (excluding ARDS/Acute Respiratory Failure)? How would each diagnosis cause a hypoxemia? 2. What is your final diagnosis for the hypoxemia? 3. What are the most likely organisms to cause the diagnosis you identified in question 2? 4. Why is a gram-negative bacteremia more serious than one caused by a gram-positive organism? 5. What is the most likely source of Mrs. X’s sepsis? 6. What is a CVP and what does a value of three indicate? Why is Mrs. X’s CVP 3? 7. What is a Procalcitonin and what is its purpose? 8. Using a computer program such as Microsoft Word, Power Point, or Visio, draw a concept map which shows the pathogenesis of a pulmonary embolus. The first box of your diagram may start with “clot formation.” The coagulation process will be assumed. The steps from clot formation, migration to the lungs and the consequences thereafter should be reflected in your diagram. The concept map must be your own work. A copy of a picture pasted into your case study is not allowed and 50 points will be deducted if this occurs. If the concept map is not completed, 50 points will be deducted from the case study. RUBIC: Rubric Detail A rubric lists grading criteria that instructors use to evaluate student work. Your instructor linked a rubric to this item and made it available to you. Select Grid View or List View to change the rubric’s layout. Content Name: Case Study Rubric Completion Points Range: 0 (0%) – 10 (10%) • All questions are completed Quality of Answers Points Range: 0 (0%) – 30 (30%) • Correct answers are given • Risk factors are correctly identified (when applicable) • Etiologies are correctly identified (when applicable) • Clinical manifestation are correctly identified (when applicable) • Definitions of terms are correct (when applicable) • Pathogenic/physiologic processes are identified correctly (when appropriate) • Diagnostic labs results are interpreted correctly (when applicable) • Differential diagnoses are plausible to the scenario & identified correctly (when applicable) • Diagnosis is correct (when applicable) Critical Analysis Points Range: 0 (0%) – 30 (30%) • Pathologic processes of the clinical scenario are explained in detail. This should include the cellular effects of the disease entity, the resultant effects on the organ and the body as a whole (when applicable). • The underlying physiologic and anatomical concepts related to the pathologic process should be used to assist with the explanation of the pathogenesis of the disease entity (when applicable). • The pathologic consequences or benefits of pharmacologic therapy are explained in detail. This should include an explanation of the underlying physiologic/pathologic process, how the process is interrupted by the pharmacologic agent, and the effects which result from the specific pharmacologic agent (when applicable). • The physiologic/pathologic process underlying the select diagnostic test is discussed to define the clinical significance of the diagnostic test (when applicable). Organization and Format Points Range: 0 (0%) – 10 (10%) • Title Page in UTA Format • Organized format, presented clearly and easy to read • Grammar and spelling correct • Concept maps are organized and easy to read (when applicable) • Case studies which require a concept map that are submitted without a concept map will have 50 points deducted. References Points Range: 0 (0%) – 10 (10%) • APA citations provided in the written text. • Reference list provided at the end of the paper. • Reference in APA format 6th edition • Professional references used to complete the assignment and are less than 6 years old. toll free 24/78889640159 Timeliness Points Range: 0 (0%) – 10 (10%) • Case study submitted before the due date. • If not submitted on time, a grade of zero will be assigned for the entire case study.

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