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- Oct 9, 2010
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Case 3
(Case 1 link - Case 2 link)
Two cases from the ED.
1:
The DNP in the emergency department calls your service saying shes "Got one for ya." 64 y/o African American female suffered sprained ankle chasing her granddaughter around the house. No other complaints, but during triage her BP was found to be 198/127. Her medications include lisinopril and a multivitamin. Her primary care physician is out of town, and she hasn't seen him in 7 months since her lisinopril dose was increased owing to missed follow-up appointment due to work-related emergency.
There are no reported constitutional symptoms, nor is there any chest pain, SOB, headache, nausea/vomiting, visual changes, arm/leg weakness, or recent syncopal episode. Exam reveals pleasant woman in NAD. There is no papilledema, RR with mid systolic ejection murmur, normal S1/S2. Lungs clear. Neuro exam is normal. Her Epic problem list includes "Stage II primary hypertension," "Osteoporosis," and "Tobacco-use disorder." FH is positive for stroke at age 85, and father still alive at 86 in Alzheimer's ward at nearby NH with multiple medical problems. She has private insurance through her job as an administrative assistant at a local university. She lives at home with her husband and is the primary caretaker of two young grand children while her daughter-in-law and son are out of the country for a 2 week archaeology dig in Malaysia.
A variety of tests were ordered in the ED and are as follows: EKG which shows NSR with incomplete RBBB pattern (unchanged from her EKG in the EMR of 3 years ago) and borderline voltage criteria for LVH. CXR is unremarkable. Troponin was 0.01 ng/mL. Serum Mg2+, TSH and free T4 were within normal ranges. Her calcium level is 8.7 mg/dL and Hgb is 11.6 g/dL. BUN/Cr are essentially the same as they were on the CMP done by her primary physician 7 months ago. You recheck BP in both arms and find 195/121 on left, 197/124 on right. Other vitals are normal.
After your exam, patient asks nurse for Advil due to a mild headache which she asserts she recently developed, citing her 8 hour stay in the ER without food and two screaming grand children. The NP wants to give her 20mg IV hydralazine and obtain non-contrast CT head since you are taking an excessive amount of time looking through the EMR and answering other pages.
2:
72-year-old male nonsmoker with a history of diabetes, coronary artery disease, and hypertension who presents with pneumonia and needs to be admitted to the hospital per the ED staff. The patient is febrile and tachypneic, has a blood pressure of 145/65, and has an oxygen saturation of 95% on room air. Physical examination is significant for rhonchi in the right lower lung fields, and a chest x-ray shows a right lower lobe infiltrate. Laboratory studies show a white blood cell count of 14,000 and no evidence of acute renal failure. Blood cultures have been obtained and he is given 500mg IV Zithromax in ED.
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1. Detail your immediate and short-term management (i.e. initial orders, admission orders).
(Case 1 link - Case 2 link)
Two cases from the ED.
1:
The DNP in the emergency department calls your service saying shes "Got one for ya." 64 y/o African American female suffered sprained ankle chasing her granddaughter around the house. No other complaints, but during triage her BP was found to be 198/127. Her medications include lisinopril and a multivitamin. Her primary care physician is out of town, and she hasn't seen him in 7 months since her lisinopril dose was increased owing to missed follow-up appointment due to work-related emergency.
There are no reported constitutional symptoms, nor is there any chest pain, SOB, headache, nausea/vomiting, visual changes, arm/leg weakness, or recent syncopal episode. Exam reveals pleasant woman in NAD. There is no papilledema, RR with mid systolic ejection murmur, normal S1/S2. Lungs clear. Neuro exam is normal. Her Epic problem list includes "Stage II primary hypertension," "Osteoporosis," and "Tobacco-use disorder." FH is positive for stroke at age 85, and father still alive at 86 in Alzheimer's ward at nearby NH with multiple medical problems. She has private insurance through her job as an administrative assistant at a local university. She lives at home with her husband and is the primary caretaker of two young grand children while her daughter-in-law and son are out of the country for a 2 week archaeology dig in Malaysia.
A variety of tests were ordered in the ED and are as follows: EKG which shows NSR with incomplete RBBB pattern (unchanged from her EKG in the EMR of 3 years ago) and borderline voltage criteria for LVH. CXR is unremarkable. Troponin was 0.01 ng/mL. Serum Mg2+, TSH and free T4 were within normal ranges. Her calcium level is 8.7 mg/dL and Hgb is 11.6 g/dL. BUN/Cr are essentially the same as they were on the CMP done by her primary physician 7 months ago. You recheck BP in both arms and find 195/121 on left, 197/124 on right. Other vitals are normal.
After your exam, patient asks nurse for Advil due to a mild headache which she asserts she recently developed, citing her 8 hour stay in the ER without food and two screaming grand children. The NP wants to give her 20mg IV hydralazine and obtain non-contrast CT head since you are taking an excessive amount of time looking through the EMR and answering other pages.
2:
72-year-old male nonsmoker with a history of diabetes, coronary artery disease, and hypertension who presents with pneumonia and needs to be admitted to the hospital per the ED staff. The patient is febrile and tachypneic, has a blood pressure of 145/65, and has an oxygen saturation of 95% on room air. Physical examination is significant for rhonchi in the right lower lung fields, and a chest x-ray shows a right lower lobe infiltrate. Laboratory studies show a white blood cell count of 14,000 and no evidence of acute renal failure. Blood cultures have been obtained and he is given 500mg IV Zithromax in ED.
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1. Detail your immediate and short-term management (i.e. initial orders, admission orders).