During your rounds in the Emergency Room, EMS brings in a 41 year old female com
ID: 3472477 • Letter: D
Question
During your rounds in the Emergency Room, EMS brings in a 41 year old female complaining of weakness, thirst, and nausea. The patient reports that she was admitted some time ago for something similar, but doesn’t remember what it was and her notes are not immediately available. She reports that she lives alone and she’s worried about insurance, as she has been out of a job where she used to be a cashier. She informs you that it’s been worse when it’s hot, because the weather in Ellensburg has been so hot. She tells you that she doesn’t get out to the store much and that she has trouble lifting her arms because of her weakness. She rates pain when trying to lift her arms as a 2/10 with 10 being the worst pain. She complains that her stomach has been upset for some time and she thinks she may have had food poisoning or something the last time she ate. She describes herself as a dainty eater and denies any disorder.
Vital Signs Heart Rate: 75 beats per minute Blood Pressure: 90/50 mmHg supine Temperature: 98.78 Respirations: 15 per minute Pulse Oximetry: 98% on room air Mental Status: Alert & Oriented to person, time, place, events, 15/15 on Glasgow Coma Scale.
Overall, the patient’s skin is pink, warm, and dry. Head/Ears/Eyes/Throat: Pupils are equal, round, and reactive. Unremarkable. Thorax: Chest rise equal bilaterally. Unremarkable. Abdomen: Unremarkable. No pain on palpation. Pelvis: Stable, no pain, weight bearing. Genitourinary/Gastrointestinal: Patient reports some recent history of diarrhea. Extremities: Arms have general weakness, cannot stand long, 2/10 pain attempting to keep arms raised. Lab Values After getting the patient on oxygen and conducting an EKG (next page), you order a STAT lab for beside arterial blood gas, and the results were as follows: Test Patient Result Reference Range FIO2 0.21 N/A pH 7.25 7.35 - 7.45 pCO2 35 mmHg 35 - 45 pO2 234 mmHg 80 - 95 HCO3 15.0 mmol/L 22 - 28 Base Excess -11 -3 to +3 Na+ 141 mmol/L 134 - 146 K+ 1.1 mmol/L 3.4 - 5.0 Cl- 116 mmol/L 98 - 106 Glucose 5.4 mmol/L 3.5-4.5
Finally, in 2-3 paragraphs, explain the following:
• Working diagnosis and etiology • Potential treatment, interventions • Simple prognosis
Explanation / Answer
Hear rate- 75 beats per minute [Normal]
Blood Pressure-90/50 mmHg , the patient has lower blood pressure [120/90 is the normal]
Supine Temperature-98.78 [Normal is 98.6°F]
Respirations- 15 per minute [Normal is 12-20]
Pulse Oximetry-98% on room air [normal is 95 to 100%]
Mental Status-Alert & Oriented to person, time, place, events 15/15 on Glasgow Coma Scale
Patient’s results with normal level {in bracket]-
FIO2 = 0.21 or 21 % [normal is also 21%]= patient is breathing in normal atmosphere.
pH 7.25 [7 .35 - 7.45]= patient has low pH
pCO2 35 mmHg [35 – 45] = patient has normal PCO2 level
pO2 =23.4 mmHg [80-95] = it cannot exceed more than 180 mmHg, so it would be 23.4 that is indication for hpoxemia.
HCO3= 15.0 mmol/L [22 – 28]
Base Excess= -11 [-3 to +3]
Na+= 141 mmol/L [134 – 146]
K+ 1.1 mmol/L [3.4 - 5.0] = hypokalemia
Cl- 116 mmol/L [98 – 106] = hyperchloremia
Glucose =5.4 mmol/L [3.5-4.5]
Patient has metabolic acidosis because she has normal PCO2 level but pH, bicarbonate ion, and lower base excess. Low potassium is related to hypokalemia and patein has hypoxemia too due to very low pO2 level. The patient has hyperglycemia due to high blood glucose and hyperchloremia due to high concentration of Chlorine.
According the above diagnosis patient has Acquired renal tubular secretory defects and further diagnosis required to find which defect. That causes by renal failure or less capability of renal system, high blood glucose.
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