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History of Present Illness: Hypertension Case

The 59-year-old male was found unresponsive at home and brought to the emergency department by EMS. His history includes hypertension treated with medications. Physical exam findings include jaundice, edema, crackles in the lungs, and abnormal liver function tests. Initial labs show elevated ammonia, PT/INR, low albumin and sodium. The provider orders an endoscopy due to concerns about liver disease.

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Bena Gichia
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182 views7 pages

History of Present Illness: Hypertension Case

The 59-year-old male was found unresponsive at home and brought to the emergency department by EMS. His history includes hypertension treated with medications. Physical exam findings include jaundice, edema, crackles in the lungs, and abnormal liver function tests. Initial labs show elevated ammonia, PT/INR, low albumin and sodium. The provider orders an endoscopy due to concerns about liver disease.

Uploaded by

Bena Gichia
Copyright
© All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd

History of Present Illness

A 59-year-old male was brought to the Emergency Department via emergency medical
services (EMS). His wife states she came home from work and found him lying on the
bathroom floor face down. She immediately called 911.  She reports that she was able to
feel a pulse and states he was breathing but "taking very shallow breaths."  EMS arrived on
the scene within 3 minutes and transferred him to the Emergency Department. He was
stabilized by the ED staff and is being transferred to your care in the Critical Care Unit.
 
Past Medical History
Client has a history of hypertension regulated with medications.
 
Past Surgical History
Appendectomy at age 28 and right knee arthroscopy at age 36.
 
Family History
Father, 82, alive with hypertension, diabetes and arthritis; mother, 78, alive with
hypertension, diabetes and chronic renal failure; son, 27, alive with no known medical
history; daughter, 25, alive with no known medical history.
 
Social History
High school graduate. Retired machinist from the Army after 20 years of service. Currently
unemployed. Lives with wife and daughter. Denies any religious affiliations. Reports
smoking 1 pack of cigarettes per day and has been smoking since he was 17 years old.
Drinks 6-12 beers per day for the past couple of years and smokes an "occasional
marijuana joint". Denies any other illicit drug use.
 
Allergies
Penicillin - causes full body rash/hives.
 
Home Medications
Hydrochlorothiazide 12.5mg PO once a day.
Lisinopril 40mg PO once a day.
 
Review of Systems
General: Difficulty concentrating. Complains of occasional bouts of confusion and frequent
insomnia. Denies fever or chills. Reports gaining around 15 pounds in the past 2 months.
HEENT: Noted mild generalized headache on rising in the morning, occurring most
mornings for at least the past month or two. No associated nausea or vomiting.
Respiratory: Mild shortness of breath with rest and activity. Denies having a cough or chest
pain. Denies any form of exercise due to shortness of breath. 
Cardiovascular: Has occasional heart palpitations. Denies any chest pain or edema in
extremities. Has blood pressure checked at the drug store about once a month, and the last
reading was 129/68 mmHg.
Abdomen/GI: Eats three meals a day which consist of a "meat and potatoes" type of diet.
Complains of constipation on occasion. Complains of bloating that "won't go away" over the
past few weeks. Denies nausea and vomiting. Denies any abdominal pain. Stool is firm,
dark, blackish color.
GU: Denies dysuria, urgency or hesitation. 
Musculoskeletal: Complains of numbness and tingling in finger tips on occasion.  States
he has developed a "mild shake" in his hands which started about 6 months ago. Denies
any joint or bone pain. 
Neuro: No history of seizures. Difficulty concentrating. Headache in the mornings,
numbness and tingling in fingertips. Denies trouble with speech, trouble swallowing, or any
other neurologic problem.
Psych: Is depressed with current life due to inability to find a job. Wife is supportive.
 
Physical Assessment
VS: T - 98.2oF oral, HR - 125 bpm/regular, R - 42, BP - 90/52 mmHg supine, Pulse ox - 90%
on room air. Ht. 5'7" Wt. 194 lbs.
General: Listless, well-developed man who appears his stated age. Interactive when
stimulated.
Skin: Warm, dry, yellow in color.  Ecchymosis noted on bilateral upper extremities.
Petechiae noted on anterior trunk.
HEENT: Normocephalic; PEERLA; scleral icterus; oropharynx clear.  Neck supple, full
painless active and passive ROM. Trachea midline, no lymphadenopathy or thyroid
enlargement. Carotid pulse bounding, no bruits.
Chest: Lung sounds diminished on auscultation with crackles at the bases.  No chest
asymmetry noted.
Cardiovascular: No abnormal heart sounds, heaves or thrills; no clubbing or cyanosis.
Bilateral extremity pitting edema 2+ noted.  Peripheral pulses equal and +1 throughout.
Abdomen/GI: Abdomen round and firm. Bowel sounds hypoactive in all 4 quadrants.
Tympany over umbilicus with dullness over lateral and flank areas of abdomen. Abdomen
distended.
GU: Bladder not palpable. Normal male genitalia.
Musculoskeletal: Full ROM in all joints; no swelling or crepitus. Bilateral strength equal in
upper and lower extremities.
Neuro: Listless, oriented x 2 (person and place only), cranial nerves II-XII intact. Deep
tendon reflexes 2+ throughout, negative Babinski.

 
 
 

1. What information in the history/physical would support a diagnosis of possible Liver


failure?

Record your thoughts here.


 
 
2. Is there another diagnosis that you might suspect? (CHF - edema, crackles, tachycardia,
tachypnea & hypotension)
Record your thoughts here.
_________________________________________________________________________
_________________________________________________________________________
__________
 
 The following admission orders were given to the nurse for the client. 

1. Admit to CCU
2. Labs: CBC, BMP, Bun/Cr, Ammonia, Serum Albumin, PT/INR, PTT, Blood alcohol
3. ABG
4. Chest X-ray
5. 12 Lead ECG
6. Call provider with results.
7. Continuous pulse oximetry
8. Vital signs every hour
9. Oxygen via NC to maintain SpO2> 92%
10. Bed rest
11. NPO
12. Strict Intake and Output
13. 0.9% NS 500mL IV bolus, then 200mL/hr continuous infusion

3. After reviewing the orders and physical exam be prepared to list the top four orders to
implement after CCU admission.
Record your thoughts here.
_________________________________________________________________________
_________________________________________________________________________
__________
 
Initial Lab Values
LAB Normal Range 10/02/17 1847

WBC 4.5 - 11.0 x 109/L  12

Hgb 13.5 - 17.5 g/dL 11

Hct 36 - 47% 30%

Platelets 150 - 450 x 109/L 45

Na 135 - 145 mEq/L 130

K 3.5 - 5.0 mEq/L 3.3

Cl 98 - 106 mmol/L 107

BUN 7 - 20 mg/dL 45

Cr 0.6 - 1.2 mg/dL 1.2

Bicarbonate  23 - 29 mEq/L 24

Glucose 70 - 140 mg/dL 50


Calcium 8.5 - 10.2 mg/dL 9

Mg 1.5 - 2.5 mEq/L 3

Phos 2.5 - 4.5 mg/dL 4.5

PT 11 - 14 sec 20

INR 0.8 - 1.2 1.7

PTT 25 - 35 sec 54

Albumin 3.5 - 5.5 g/dL 2.4

NH4 15 - 45 mcg/dL 45

Blood Alcohol < 0.01g/dL 0.2


0.08 = legal intoxication limit
 
4. After reviewing the initial lab values and the physical exam of the client, what lab(s) would
be most concerning to the nurse and why?
Record your thoughts here.
_________________________________________________________________________
_________________________________________________________________________
__________
 
5. What is your rationale for choosing the labs you chose?
Record you thoughts here.
_________________________________________________________________________
_________________________________________________________________________
__________
 
Arterial Blood Gases:
pH 7.48; PaCO2 28; PaO2 60; HCO3 24
 
6. Interpret the above ABG results.
_______________________________________________________________________
_______________________________________________________________________
__________
 
12 Lead ECG

 
7. Interpret the 12 Lead ECG above. 
Record you thoughts here.
____________________________________________________________________
____________________________________________________________________
__________
 
 

 The provider has decided the client needs an endoscopy STAT.  You have
received orders to prep the client for the endoscopy that is scheduled in 2
hours.  After your last assessment you report the client has not urinated since
admission despite the fluid bolus and maintenance fluids.  The provider has
ordered another NS fluid bolus of 500mL/hr and an indwelling foley catheter to
be inserted to measure strict Intake and Output.

 
8.  What do you suspect is the main reason the provider ordered an endoscopic study?
Record your thoughts here.
____________________________________________________________________
____________________________________________________________________
__________
 
9. Why do you believe the provider ordered an additional NS bolus?
Record your thoughts here.
____________________________________________________________________
____________________________________________________________________
__________
 

 After the additional NS bolus was infused, the nurse notes these VS: RR 40
breaths/min, HR 99 bpm, BP 97/62 mmHg supine, SpO2 92% on 6L NC.  Lungs
are diminished at the apices and crackles are auscultated throughout the
lower lobes about ½ way up the lungs bilaterally. Urine output increased to
15mL/hr. 

 
10 The nurse calls the provider and reports the new assessment findings. What would the
nurse expect to be ordered for the client?
Record your thoughts here.
 
 
The nurse has received a phone call from the endoscopy department that they
will be sending for the client shortly.  As the nurse hangs up the phone, the wife
runs out of the room because the client is vomiting "dark brown stuff".  The
nurse runs into the room and finds the client lying in bed with coffee ground
emesis all over him. 
 
11. What might the clinical signs and symptoms indicate?
Record your thoughts here.
____________________________________________________________________
____________________________________________________________________
__________
 
 

 The nurse notifies the provider and the client is sent immediately to
endoscopy for a scope.  The endoscopy procedure was not able to visualize
anomalies in the lining of the stomach but was able to determine the client had
several varicose veins in the lower part of his esophagus which were banded
during the procedure.

 
12. What are your thoughts about the varicose veins being banded?
Record your thoughts here.
________________________________________________________________
_____
________________________________________________________________
_____

 The provider ordered CBC q 8 hours x 3 and a type and crossmatch. See
results below:

 
LAB Normal Range 10/02/17 10/02/17 10/03/17 10/03/17
1847 2218 0415 1022

WBC 4.5 - 11.0 x 12 11.6 11.2 11


109/L 

Hgb 13.5 - 17.5 g/dL 11 10.2 8.6 7.7

Hct 36 - 47% 30% 28% 24% 22%

Platelets 150 - 450 x 45 45 43 42


109/L
 
 
13. Prioritize your top concerns/problems for this client and your rationale for the
prioritization.
Record your thoughts here.
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________

Common questions

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The use of NS (normal saline) fluid boluses followed by continuous infusion serves to address hypovolemia indicated by hypotension and elevated heart rate, suggesting potential volume depletion. It aims to optimize intravascular volume, thereby stabilizing blood pressure and potentially improving renal perfusion, reflected in the low urine output despite existing fluid therapy .

The patient's lab values indicate significant concerns: low hemoglobin and hematocrit levels suggest anemia, while elevated blood urea nitrogen (BUN) and creatinine levels indicate potential kidney impairment. The low sodium and potassium levels could point to an electrolyte imbalance. The critical values such as prolonged PT, elevated INR, and ammonia levels on the higher end suggest liver dysfunction, collectively necessitating immediate interventions like fluid resuscitation, administering medication to manage liver function, and possibly blood transfusions for anemia .

The patient's smoking and alcohol consumption are significant lifestyle factors that likely contributed to his current condition. Smoking a pack per day for decades would place the patient at risk for cardiovascular and respiratory issues, while chronic alcohol consumption of 6-12 beers daily might have significantly damaged his liver function, leading to jaundice, coagulopathy (as indicated by prolonged PT and elevated INR), and possibly liver failure .

The patient's prolonged PT and elevated INR suggest impaired coagulation, likely from liver dysfunction, risking spontaneous bleeding. Low platelet levels further exacerbate the risk of hemorrhage. Anticipated complications include gastrointestinal bleeding or other forms of internal bleeding, necessitating close monitoring and possible interventions such as vitamin K administration, platelet transfusions, or consults for specialized management like endoscopy .

The patient's vital signs, including a high heart rate of 125 bpm, low blood pressure of 90/52 mmHg, and diminished lung sounds with crackles, suggest compromised cardiac function possibly due to congestive heart failure (CHF). Tachycardia implies increased cardiac workload, while hypotension may indicate poor cardiac output and/or volume depletion, aligning with possible CHF exacerbation influencing fluid overload and pulmonary congestion .

Continuous monitoring and bed rest are essential for this patient due to his unstable condition, characterized by the risk of sudden hemodynamic changes, respiratory distress, and potential internal bleeding. Continuous monitoring allows for immediate detection and response to critical events such as drops in SpO2 or blood pressure. Bed rest minimizes physical exertion, reducing stress on his compromised cardiovascular and respiratory systems and lowering the risk of exacerbating his condition .

The ABG results show a respiratory alkalosis, as indicated by the elevated pH of 7.48 and a low PaCO2 of 28 mmHg. The PaO2 is also low at 60 mmHg, indicating hypoxemia. This suggests that the patient is hyperventilating, likely due to underlying respiratory distress, contributing to an acute alkalosis state and necessitating attention to his oxygenation and ventilation status .

Endoscopy is likely indicated to assess and manage potential upper GI bleeding source suspected due to 'coffee ground' emesis. The procedure can identify and treat variceal lesions, which could be the bleeding source due to portal hypertension likely related to liver dysfunction, necessitating timely intervention to prevent significant blood loss or further complications .

The patient's symptoms and history suggest possible liver failure. Supporting evidence includes the scleral icterus, yellow skin indicating jaundice, and altered laboratory values such as low albumin, which could indicate liver dysfunction. Additionally, the low platelet count, prolonged prothrombin time (PT), and elevated INR hint towards impaired liver function impacting coagulation pathways .

The 'coffee ground' emesis indicates gastrointestinal bleeding, possibly from the upper GI tract. Given the finding of esophageal varices, it is likely that these veins have ruptured, leading to bleeding. Immediate management should focus on stabilizing the patient's hemodynamics through IV fluids, possibly blood transfusions, and addressing variceal bleeding potentially through endoscopic intervention like band ligation, which was planned .

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