ANP650wk9

History and Physical

CC: “It has been burning when I urinate and I’m having right back pain.”

History obtained from the patient and previous admission notes.

HPI: Patient is a 70-year-old female with a past medical history of HTN, HLD, shingles, DM type 2 and inflammatory arthropathy. Patient presents to the ER with right flank pain, cough, fever, and chills x 3 days. She describes the pain as being sharp, and constant and rates it as a 10/10. Nothing makes it worse, but Tylenol takes the edge off. She reports that she went to an urgent care clinic 5 days ago with same symptoms and was treated with Bactrim but there has been no improvement.

ROS:

Allergies: None

Chills, night sweats, febrile, denies changes in weight, weakness, or SOB

Head and neck: no jugular vein distention, normocephalic

Cardiovascular: Denies edema, dyspnea on exertion, palpitations, orthopnea

Respiratory: Denies SOB, hemoptysis, sputum, or cough

Gastrointestinal: denies diarrhea, or blood in stools, constipated and vomiting

Musculoskeletal: Denies muscle or joint pain

Neurologic: Denies tingling, dizziness, or weakness

Integumentary: Denies any abnormalities

PMH:

HTN

HLD

Shingles

DM type II

Past surgical hx:

Laparoscopic cholecystectomy

Hysterectomy

Family Hx:

Mother- died from breast cancer at the age of 64

Father- died from colon cancer at the age of 69

Social Hx:

ETOH: social drinker only (1-2 x a month)

Denies illicit drug use

Denies Tobacco use

Home medications

Zocor 20mg QHS

Zestril 20mg QD

Bactrim DS 800mg BID

Tylenol 650mg Q6 PRN

Lantus 34units QHS

Exenatide 2mg Q Sunday

Terbinafine 250mg QD

Physical exam:

T: 99.5 F, BP: 115/71, P: 110, RR: 26, O2 sats: 97% on room air

General: Alert and oriented x 4

HEENT: Head is normocephalic, PERRLA, mucous membranes moist and pink

Neck: no jugular vein distention noted

Respiratory: LCTA, no rales, rhonchi, or wheezing

CV: Regular rate and rhythm, no murmurs, rubs or gallops

Neurological: Awake, alert, and oriented x 3

ABD: Abdomen is soft, non-distended, bowel sounds active x 4, no guarding or rebound tenderness

Extremities: clean, dry, intact, and warm. No edema noted

Psychiatric: calm, cooperative and answers questions appropriately

Labs:

WBC- 10

HGB- 11

HCT- 31

PLT- 230

NA- 123

CL- 96

BUN- 40

CREAT- 2.46

HCO3-: 17

GLUC- 156

K+- 4.3

UA/Culture- Escherichia coli

Imaging:

CT- negative

Differential Diagnosis:

The role of the ACNP is to provide an accurate list of differential diagnosis. It is important that it is done in a timely many for a patient’s best opportunity for a positive outcome. The DD list helps determine a final diagnosis (Cheng & Granger, 2018).

Acute kidney Injury N17.1: Symptoms include elevated creatinine and can possibly be reversed if treated in a timely manner (Kanuka & Kosner, n.d.).

Severe sepsis A41.5: Sepsis is a life-threatening illness that can cause multiorgan failure. Symptoms includes hypotension, tachycardia, hypotension, fever, and leukocytosis (Revere, Carson, & Tinley, 2018).

Urinary Tract infection N39.0: burning or pain with urination, flank pain, urinary frequency, and fever

Assessment:

The patient is a 70-year-old female with a history of HTN, HLD, DM type 2, and inflammatory arthropathy who presented to the ER with right flank pain, fever, burning with urination, and hematuria. Consults and labs ordered. Admitted to the ICU for acute kidney injury, septic shock, hyponatremia, and urinary tract infection as confirmed with UA, C&S.

Plan:

IV fluids

Cortisol 200mg QD

IV Rocephin 2gm Q24h (infection)

IV Levophed 8mg titrate to keep MAP 50-70mmHg

IV Vitamin C 1500mg Q6h x 3 days

IV Vitamin B1 200mg BID x 3 days

Keep blood sugars 110-180

Daily repeat labs

According to Larry et al. (2017), the early use of vitamin B1, corticosteroids, and vitamin C together decreases the mortality rate of organ failure as evidenced by a study that was done and showed a reduction in mortality rates and acute kidney injuries.

Geriatric Specific

When it comes to the older population, they have a greater risk of prolonged illness and repeated hospitalizations due to increased co-morbidities. When you add sepsis to the equation the leads to an increase in ICU admissions for the elderly. Sepsis is a life-threatening illness that causes widespread inflammation in the body. Inflammation and blood clotting during sepsis causes reduced blood flow to limbs and vital organs that can lead to organ failure and even death. This inflammatory response is identified when two of four different criteria are met. In the hospital it was issue a SIRS alert. These four criteria are fever, tachypnea, tachycardia, fever, and leukocytosis. A goal directed therapy is imperative within the first six hours, antibiotics must be started within the first hour of diagnosing. Vasopressor therapy is used in septic patients to control mean arterial pressure and organ perfusion. With a timely initiation of evidence-based protocols for sepsis, there has been and in improvement in outcomes (Barry, 2018).

Reference:

Barry, E. (2018). How to Recognize Sepsis Early in Adults: The First Six Hours. American Family

Physician, 88(1), 44-53.

Carson, G., Tinley, B., & Reviere, M. (2017). Sepsis in Adults: Diagnosis and Prognosis. Retrieved

from https://UpToDate.com

Cheng, A., & Granger, C. (2018). Improving Health Care. The New Zealand Journal of Medicine,

161(15), 1463

Kanuka, M., & Kosner, A., (2018). Management of Acute Kidney Injury in Adults. World Journal

of Critical Care Medicine, 3(3), 33-51