HPI
Mimsmore
RNNUR235CaseStudyAdultIILabandDiagAnalysisAPAPaper.docPAGE
1
Nursing 235: Adult Health II
Laboratory Analysis Case Scenario
Patient Initials: KH Age: 60
Height: 65 in
Weight: 67.13 kg
HPI
KH presented to the ED with c/o bug bite on L thigh that occurred about 10 days ago that has turned into an abscess “as big as a personal sized watermelon.” Patient also reported urinary burning, frequency, and urgency. The ED, WBC 37,000, glucose 317, bicarbonate 13, anion gap 25, large amount of acetone, HgbA1C 10.3. Patient was admitted to the hospital for evaluation and management of DKA, DVT, abscess, and UTI.
Past Medical/Surgical History:
· Type 2 Diabetes Mellitus
· Previous tobacco use (1/2 pack per day)
· MVA 7/13/20: pain in pelvis and knees since accident
Significant Clinical Events:
8/23/20
· Wound culture: staph aureus, methicillin sensitive
· Blood culture: no growth after 5 days (determined on 8/28/10)
· Urine analysis indicates infection and DKA
· Insulin drip for DKA
· IV antibiotics for UTI, multiple abscesses
· IV antifungals for multiple abscesses & topical antifungal for yeast infection
8/24/20
· Deep muscle abscess extends to femur (visualized via CT)
· I&D done in OR discovered diffuse myositis & muscle necrosis
· S/p insulin drip for DKA treatment
· Wound nurse consult
· Infectious disease consult
8/26/20
· I&D done in OR on L thigh, R groin abscess
· Patient experience bleeding post-op
· SCD and TED hose prescribed for DVT
8/28/20
· d/c Coumadin due to post procedure bleeding, switched to Lovenox
8/29/20
· bleeding from wound, changed lovenox to heparin
· anemia due to blood loss s/p I&D, received 2 units packed RBC
· Constipation for 1 wk, senna, colace, lactulose
8/30/20
· blood glucose 340-360 mg/dL all day
· patient complains of recent onset visual disturbances (since hospitalization on 8/23/10)
· notify MD, increase levemir to 32 units daily
· MD d/c IV antibiotic and heparin, change to PO antibiotics and coumadin
|
Test/Result |
Admit 8/23/20 |
Sun 8/29/20 |
Mon 8/30/20 |
|
|
Hemoglobin (g/dL) |
13.8 |
7.4L |
9.1L |
|
|
Hematocrit (%) |
42.2 |
21.1L |
25.8L |
|
|
RBC (M/uL) |
4.35 |
2.28L |
2.82L |
|
|
WBC (K/Ul) |
37.2H |
11.4H |
14.2H |
|
|
MCV (FL) |
97.1H |
92.5 |
91.7 |
|
|
MCH (PG) |
31.7 |
32.3 |
32.3 |
|
|
MCHC (g/dL) |
32.7 |
35 |
35.2 |
|
|
RDW (%) |
15.1H |
15.8H |
15.5H |
|
|
PLT (K/uL) |
461H |
408 |
428H |
|
|
MPV (FL) |
7.5 |
6.6 |
6.3 |
|
|
PT (Sec.) |
n/a |
9.7 |
10.0 |
|
|
INR |
n/a |
0.93 |
0.96 |
|
|
PTT (Sec.) |
n/a |
29.4 @ 0600 30.3 @ 1400 |
24.6 @ 0600 48.1 @ 1400 |
|
|
guaiac |
|
|
negative |
|
|
BUN (mg/dL) |
15 |
7L |
6L |
|
|
Creatinine–mg/dl |
0.96 |
0.29L |
0.36L |
|
|
GFR AF |
54 |
n/a |
>60 |
|
|
BNP |
277H |
|
|
|
|
AGAP |
25.0H |
8.0 |
9.0 |
|
|
Chlroide (mmol/L) |
92L |
102 |
98 |
|
|
CO2 (mmol/L) |
13L |
24 |
25 |
|
|
Potassium (mmol/L) |
4.8 |
4.1 |
4.0 |
|
|
Sodium (mmol/L) |
130L |
134L |
132L |
|
|
Glucose (U/L) |
397H |
266H |
368H |
|
|
HgbA1C
|
10.3H |
|
|
|
|
Urinalysis Color Yellow |
yellow |
|
|
|
|
Appearance Clear |
Hazy |
|
|
|
|
Spec. Gravity 1.002-1.030 |
1.025 |
|
|
|
|
PH 4.5-8.0 |
5.5 |
|
|
|
|
Protein Negative |
200mg/dL |
|
|
|
|
GLU Normal |
1000mg/dL |
|
|
|
|
Ketones Negative |
>150 |
|
|
|
|
Blood Negative |
300 |
|
|
|
|
Urobilinogen Normal |
2mg/dL |
|
|
|
|
Leuk Ester Negative |
500 |
|
|
|
Dx. Tests Date and Client Results
|
Gram Stain
|
8/23/10 & 8/25/10 wound culture: gram positive cocci staph like |
|
Cultures/ Sensitivities
|
8/23/10 blood culture: no growth after 5 days (8/28/10) 8/23/10 wound culture of groin abscess: staph aureus, sensitive to methicillin, clindamycin, erythromycin, oxacillin, naficillin, amoxicillin, clavulanic acid, ampicillin, sulbactam, SXT, most parenteral and oral cephalosporins 8/23/10 urine culture: >100,000 CFU/mL staph aureus sensitive methicillin, nitrofurantoin, oxacillin, SXT 8/25/10 culture abscess L bottom: staph aureus (see above wound culture for sensitivities) |
|
Therapeutic Drug Levels |
PT (9-11.5 sec) and INR (2.0-3.0) evaluate therapeutic drug levels of coumadin, PTT (60-70 sec) evaluate therapeutic levels of heparin. |
Dx. Tests Date and Client Results
|
CXR
|
8/23/10 CXR: cardiac mediastinal silhouettes normal, lungs are clear. No pleural effusion or indication of CHF. |
|
CT/US/ Nuc Med/ Spec Proc
|
8/26/10 CT abdomen & pelvis without contrast: inflammatory mass-like density with subcutaneous of R groin containing central air bubbles presumably secondary to recent drainage/intervention. No well-organized fluid collection in region. Body wall and intra-abdominal edema. Few non-specific bubbles of air within lower anterior abdominal wall. Abscess in proximal L thigh and L buttock not imaged. 8/26/10 CT pelvis with IV contrast: superficial L medial buttock abscess 5-6cm diameter extending inferiorly and connected to large deep muscle abscess, extends to femur measures 8x10cm
|
|
Cardiac monitoring
|
Measure and compare with report: PR interval: QRS: QT interval: P-P interval regular: R-R interval regular: |
|
Medications |
|
Cefazolin (Ancef) 2g/D5W 110mL IVPB q 8hrs infuse over 30 min |
|
Clindamycin (Cleocin) 900mg IVPB infuse over 30 min |
|
Fluconazole (Diflucan) 100mg PO Q 24hrs |
|
Heparin 100 units/mL standard infusion
|
|
Warfarin (Coumadin)
|
|
Nystatin Topical |
|
Insulin Aspart 0-14 units SQ 4 times daily ac/hs |
|
Insulin Detemir (Levemir) 32 units SQ daily |
|
Polyethylene glycol (Golytely) 400mL PO one time |
|
Acetaminophen (Tylenol) 650mg PO q 4 hrs prn
|
|
Oxycodone (Oxycontin) 5 mg PO Q 4 hrs prn |
|
Morphine (Duramorph) 4mg IV Q 3hrs prn |
|
Hydromorphone (Dilaudid) 1mg IV Q 3hrs prn |
|
Calcium Carbonate (Tums) chewable 500mg PO 3x daily prn |
|
Promethazine (Phenergan) 6.25mg IV q 4hrs prn |
|
Sennosides/ docusate sodium 8.6mg/50mg 1 tablet PO BID prn
|
|
Trazadone (Desyrel) 25mg PO hs prn
|
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