J.B. is an overweight 58-year-old man who has had swelling in his left foot and ankle and pain in his left calf for six days
Ms. K.Z., a 22-year-old university coed, was rushed to the emergency room 35 minutes after sustaining multiple stab wounds to the chest and abdomen by an unidentified assailant. A witness had telephoned 911.
Paramedics arriving at the scene found the victim in severe acute distress. Vital signs were obtained: HR 128 (baseline 80), BP 80/55 (baseline 115/80), RR 37 and labored. Chest auscultation revealed decreased breath sounds in the right lung consistent with basilar atelectasis (i.e., collapsed lung). Pupils were equal, round, and reactive to light and accom- modation. Her level of consciousness was reported as “awake, slightly confused, and com- plaining of severe chest and abdominal pain.” Pedal pulses were absent, radial pulses were weak, and carotid pulses were palpable. The patient was immediately started on intravenous lactated Ringer’s solution at a rate of 150 mL/hr.
Patient Case Question 1. With two words, identify the specific type of hypovolemic shock in this patient.
An electrocardiogram monitor placed at the scene of the attack revealed that the patient had developed sinus tachycardia. She was tachypneic, became short of breath with conver- sation, and reported that her heart was “pounding in her chest.” She appeared to be very anxious and continued to complain of pain. Her skin and nail beds were pale but not cyan- otic. Skin turgor was poor. Peripheral pulses were absent with the exception of a thready brachial pulse. Capillary refill time was approximately 7–8 seconds. Doppler ultrasound had been required to obtain an accurate BP reading. The patient’s skin was cool and clammy. There was a significant amount of blood on her dress and on the pavement near where she was lying.
Patient Case Question 2. Based on the patient’s clinical manifestations, approximately how much of her total blood volume has been lost?
During transport to the hospital, vital signs were reassessed: HR 138, BP 75/50, RR 38 with confusion. She was diagnosed with hypovolemic shock and IV fluids were doubled. Blood samples were sent for typing and cross-matching and for both chemical and hemato- logic analysis.
Laboratory test results are shown in Patient Case Table 6.1:
PaO^2: 53mm Hg
PaCO^2: 52mm Hg
SaO^2: 84% on RA
Patient Case Question 3. How many units of whole blood are minimally required?
Patient Case Question 4. Is it necessary that sodium bicarbonate be administered to the
patient at this time?
Oxygen was started at 3 L/min by nasal cannula. Repeat arterial blood gases were: PaO2 82 mm Hg, PaCO2 38 mm Hg, pH 7.36, SaO2 95%.
Patient Case Question 5. Are arterial blood gas results improving or deteriorating?
ER physicians chose not to start a central venous line. An indwelling Foley catheter was inserted with return of 180 mL of amber-colored urine. Urine output measured over the next hour was 14 mL. Ms. Z’s condition improved after resuscitation with 1 L lactated Ringer’s solution and two units packed red blood cells over the next hour.
Patient Case Question 6. Based on urine output rate, in which class of hypovolemic shock can the patient be categorized at this time?
Laboratory blood test results are shown in Patient Case Table 6.2
Patient Case Question 7. Explain the pathophysiology of the abnormal BUN and Cr.
Patient Case Question 8. Does the patient have a blood clotting problem?
Patient Case Question 9. Explain the pathophysiology of the abnormal serum glucose concentration.
The patient was taken to the operating room for surgical correction of lacerations to the right lung, liver, and pancreas. There, she received an additional six units of type B+ blood. Surgery was successful and the patient was admitted to the ICU for recovery with the fol- lowing vital signs: HR 104, BP 106/70, RR 21, urinary output 29 mL/hr. A repeat BUN and Cr revealed that these renal function parameters had returned to near-normal values (23 mg/dL and 1.4 mg/dL, respectively).
Patient Case Question 10. Based on clinical signs after surgery, in which class of hypov- olemic shock can the patient be categorized at this?
E.W. is a 40-year-old African American male, who has had difficulty controlling his HTN lately. He is visiting his primary care provider for a thorough physical examination and to renew a prescription to continue his blood pressure medication.
- Chronic sinus infections • Hypertension for approximately 11 years • Pneumonia 6 years ago that resolved with antibiotic therapy
- Onemajorepisodeofmajordepressiveillnesscausedbythesuicideofhiswifeof15years, 5 years ago
- No surgeries
- Father died at age 49 from AMI; had HTN • Mother has DM and HTN • Brother died at age 20 from complications of CF • Two younger sisters are A&W
The patient is a widower and lives alone. He has a 15-year-old son who lives with a mater- nal aunt. He has not spoken with his son for four years. The patient is an air traffic con- troller at the local airport. He smoked cigarettes for approximately 10 years but stopped smoking when he was diagnosed with HTN. He drinks “several beers every evening to relax”
and does not pay particular attention to the sodium, fat, or carbohydrate content of the foods that he eats. He admits to “salting almost everything he eats, sometimes even before tasting it.” He denies ever having dieted. He takes an occasional walk but has no regular daily exercise program.
Patient Case Question 1. Identify six risk factors for hypertension in this patient’s history.
- Hydrochlorothiazide 50 mg po QD • Pseudoephedrine hydrochloride 60 mg po q6h PRN • Beclomethasone dipropionate 1 spray into each nostril q6h PRN
Patient Case Question 2. Why is the patient taking hydrochlorothiazide and what is the primary pharmacologic mechanism of action of the drug?
Patient Case Question 3. Why is the patient taking pseudoephedrine hydrochloride and what is the primary pharmacologic mechanism of action of the drug?
Patient Case Question 4. Why is the patient taking beclomethasone dipropionate and what is the primary pharmacologic mechanism of action of the drug?
Rash with penicillin use
- States that his overall health has been fair to good during the past 12 months • Weight has increased by approximately 20 pounds during the last year • Denies chest pain, shortness of breath at rest, headaches, nocturia, nosebleeds, and
hemoptysis • Reports some shortness of breath with activity, especially when climbing stairs, and that
breathing difficulties are getting worse • Denies any nausea, vomiting, diarrhea, or blood in the stool • Self-treats occasional right knee pain with OTC extra-strength acetaminophen • Denies any genitourinary symptoms
Patient Case Question 5. What is the most clinically significant information related to HTN in this review of systems?
Physical Exam and Lab Tests
The patient is an obese black man in no apparent distress. He appears to be his stated age.
See Patient Case Table 5.1:
Average BP 155/96 mm Hg (sitting)
HR 73 and regular
Wt 221 lb
RR 15 and unlabored
Patient Case Question 6. Identify the two most clinically significant vital signs relative to this patient’s HTN.
- TMs intact and clear throughout • No nasal drainage • No exudates or erythema in oropharynx • PERRLA, pupil diameter 3.0 mm bilaterally • Sclera without icterus • EOMI • Funduscopy reveals mild arteriolar narrowing with no nicking, hemorrhages, exudates, or
Patient Case Question 7. What is the significance of the HEENT examination?
- Supple without masses or bruits • Thyroid normal • () lymphadenopathy
- Mild basilar crackles bilaterally • No wheezes
- RRR • Prominent S3 sound • No murmurs or rubs
Patient Case Question 8. Which abnormalities in the heart and lung examinations may be related and why might these clinical signs be related?
- Soft and ND • NT with no guarding or rebound • No masses, bruits, or organomegaly • Normal BS
- Normal size prostate without nodules or asymmetry • Heme () stool • Normal penis and testes
- No CCE • Limited ROM right knee
- No sensory or motor abnormalities • CNs II–XII intact • Negative Babinski • DTRs2
- Muscle tone 5/5 throughout
Patient Case Question 9. Are there any abnormal neurologic findings and, if so, might they be caused by HTN?
Laboratory Blood Test Results:
Na 139 meq/L
RBC 5.9 million/mm3
Mg 2.4 mg/dL
K 3.9 meq/L
PO4 3.9 mg/dL
Cl 102 meq/L
AST 29 IU/L
Uric acid 7.3 mg/dL
HCO3 27 meq/L
ALT 43 IU/L
Glu, fasting 110 mg/dL
BUN 17 mg/dL
Alk phos 123 IU/L
- cholesterol 275 mg/dL
Cr 1.0 mg/dL
GGT 119 IU/L
HDL 31 mg/dL
Hb 16.9 g/dL
- bilirubin 0.9 mg/dL
LDL 179 mg/dL
- protein 6.0 g/dL
Trig 290 mg/dL
Ca 9.3 mg/dL
PSA 1.3 ng/mL
Patient Case Question 10. Why might this patient’s GGT be abnormal?
Patient Case Question 11. Identify three other clinically significant lab tests above.
See Patient Case Table 5.3:
Appearance Clear and amber in color
Patient Case Question 12. What is the clinical significance of the single abnormal urinalysis finding?
Increased QRS voltage suggestive of LVH
Moderate LVH with EF 46%
Patient Case Question 13. What is the likely pathophysiologic mechanism for LVH in this patient?
Patient Case Question 14. What does the patient’s EF suggest?
Peripheral Arterial Disease:
Mrs. R.B. is a 52-year-old woman with a 40-year history of type 1 diabetes mellitus. Although she has been dependent on insulin since age 12, she has enjoyed relatively good health. She has been very careful about her diet, exercises daily, sees her primary care provider regularly for checkups, and is very conscientious about monitoring her blood glucose levels and self- administration of insulin. She is slightly overweight and was diagnosed with hypertension four years ago. Her high blood pressure has been well controlled with a thiazide diuretic. She does not smoke and rarely drinks alcoholic beverages.
Mrs. B. was planning to shop at the local supermarket on Saturday, but her son tele- phoned her at the last minute and apologized that he had to work and could not drive her. Since she had only a few necessary items to pick up, she decided to walk the five blocks to the store. Rather than wear her usual walking shoes, she wore a pair of more fashionable shoes. Upon her return home, Mrs. B. removed her shoes and noticed a small blister on the ball of her right foot. She felt no discomfort from the blister. However, two days later, she was alarmed when she found that the blister had developed into a large, open wound that was blue-black in color. For the next two days, she carefully cleansed the wound and covered it with sterile gauze each time. The wound did not heal and, in fact, became pro- gressively worse and painful. Her son urged her to seek medical attention, and five days after the initial injury she made an appointment with her primary care provider.
Patient Case Question 1. Identify this patient’s two most critical risk factors for peripheral arterial disease.
Mrs. B.’s foot wound is approximately 1 inch in diameter and contains a significant amount of necrotic tissue and exudate. Furthermore, there is a lack of pink granulation tissue—an indication that the wound is not healing. The patient has a history of bilateral intermittent claudication, but denies pain at rest and recent numbness, tingling, burning sensations, and pain in her buttocks, thighs, calves, or feet. Examination of the peripheral pulses revealed normal bilateral femoral and popliteal pulses. However, the right dorsalis pedis artery and right posterior tibial artery pulses were not palpable. The patient has no history of coro- nary artery disease or cerebrovascular disease.
Patient Case Question 2. What level of peripheral arterial disease is suggested by her pulse examination: iliac disease, femoral disease, superficial femoral artery disease, or tibial disease?
Patient Case Question 3. Briefly describe the locations of the dorsalis pedis artery and posterior tibial artery pulses.
Physical Examination and Laboratory Tests
A pallor test revealed level 3 pallor in the right lower leg and foot and level 1 pallor in the left lower extremity. Ankle-brachial tests were conducted.
Left brachial systolic pressure: 130 mm Left ankle systolic pressure: 110 mm Right brachial systolic pressure: 125 mm Right ankle systolic pressure: 75 mm
Patient Case Question 4. What conclusions can be drawn from the pallor and ankle- brachial test results?
A careful physical examination of the patient’s feet and legs revealed that both feet were cool to the touch and the toes on her right foot were slightly cyanotic. However, there was no mottling of the skin and sensory, reflex, and motor functions of both legs were intact. Her vital signs are shown in Patient Case Table 8.1.
P 95 and regular
Wt 145 lb
Patient Case Question 5. Why is it likely that the patient’s body temperature is elevated?
A sample of the patient’s blood was drawn and submitted for analysis.
Laboratory Blood Test Results
See Patient Case Table 8.2
Patient Case Table 8.2 Laboratory Blood Test Results
Hb 15.1 g/dL
ESR 20 mm/hr
BUN 10 mg/dL
Na 139 meq/L
Creatinine 0.7 mg/dL
K 4.3 meq/L
T cholesterol 291 mg/dL
Cl 108 meq/L
LDL 162 mg/dL
Glu, fasting 210 mg/dL
HDL 26 mg/dL
Patient Case Question 6. What major conclusions can be drawn from the patient’s blood work?
Patient Case Question 7. Does Mrs. B. have any signs of renal insufficiency, a common chronic complication of diabetes mellitus?
The patient was hospitalized and both wound and blood cultures were started. Mrs. B. was treated with broad-spectrum antibiotics while waiting for culture reports. The wound was packed with saline-soaked Kerlix gauze to facilitate debridement of necrotic tissue. The patient was provided continuous insulin by IV with frequent monitoring of blood glucose concentrations. Serum glucose levels were maintained at 80–100 mg/dL. An electrocardio- gram was normal. Wound and blood culture reports were eventually completed. The wound was contaminated with gram-positive bacteria, but the blood culture was negative.
Magnetic resonance angiography of the right lower extremity was subsequently per- formed and a right tibial artery obstruction was identified. The section of diseased vessel was short (3.0 cm), but there was 70% narrowing of the artery. The angiogram also showed some degree of collateral circulation around the obstructing lesion. The patient underwent suc- cessful percutaneous angioplasty of the diseased vessel and placement of a stent to restore blood flow. The foot wound showed significant signs of healing after several days of bedrest and continued antibiotic therapy. A decision to perform an amputation of the right foot was averted.
Patient Case Question 8. Based on the information provided in the patient’s clinical workup, what type of medication is ultimately necessary?
Patient Case Question 9. Why is it unlikely that a thrombus or embolus contributed to arterial obstruction in this case?
Patient Case Question 10. What is “Legs for Life”?