Case Study - Mr Marconi, age 76. Bought in to the Emergency department

Mr Marconi is a 76 year Italian man who has a basic understanding of English. His current health conditions include insulin dependent type II diabetes, hypertension, hyperlipidemia and congestive heart failure.

He has been residing at a nursing home for the past twelve months. He has an unmarried daughter 56 years old who stays nearby. His wife passed away a year ago and he grieves for her today.The nurse at the nursing home arranged transfer to hospital when Mr Marconi became short of breath and stated he had chest pain. Mr Marconi has been unwell for the past 3 days with fevers; he has been refusing to eat and drink due to feeling exhausted. He had a fall this morning whilst trying to walk to the bathroom, his left wrist is swollen.

On arrival, Mr Marconi states that he has chest pain when breathing in, he is coughing up yellow phlegm and he feels exhausted. He states that he has lost several kilos over the past two weeks. His vital signs include:

• Respiratory Rate: 28 bpm (shallow with pain on inspiration)
• SaPO2: 91% (2L/min)
• Blood Pressure: 105/70
• Pulse Rate: 105 and weak • Temperature: 38.9
• BGL: 4.5
• Weight: 78 kilos
• Height: 174 cms

His current medications include Atenolol (beta blocker), Ramipril (angiotensin converting enzyme inhibitor) Lantus (insulin) and Lipitor (reduces cholesterol). He has no known allergies.

The doctor has noted the following in the medical record:
• Decreased air entry and bronchial breath sounds, left lung
• Dehydration- IV fluids commenced, 1L to run over 8 hours
• Blood sugar 4.5, requires close monitoring.

Answer the following ten questions related to Mr Marconi's health care:

1. Describe the process of coronary artery atheroma formation.

A Factors that trigger endothelial inflammation

In Most cases the endothelial inflammation is triggered by cardiovascular risk factors: hypercholesterolemia, hypertension, smoking or diabetes.

B How high and low density lipoproteins contribute to atheroma formation

C The role of macrophages

2 You are asked to document Mr Marconi's neurovascular observations (left wrist) during the admission assessment. Discuss the following in relation to this assessment:

a  List the 5 parts of this assessment.
• Radial Nerve-Sensation & Motor function Nerve-Sensation & Motor function
• Ulna Nerve-Sensation & Motor function
• Colour
• Temperature
• Swelling
• Pulse

B Explain how each of these assessments evaluates Mr Marconi's left wrist injury.

The doctor orders a chest and left forearm X-ray. The Registered Nurse asks you to organise his transfer to the radiology department. He is scheduled for his X-ray at 06:45

3 Outline the preparation required to transfer Mr Marconi to the radiology department for these tests. Include the following aspects in your answer:

A Forms and documentation required

Request/consent form is clear and legible and contains:
• Patient's first and family name, date of birth and medical record number or full address
• Procedure requested including side (if applicable)
• Clinical history
• Name of Doctor
• Patient Number if any

B Review the vital signs on the Adult Deterioration Detection System (ADDS) chart. List each of the vital signs recorded at 06:30 in the table below

C List the abnormal signs and then describe the abnormality using correct terminology eg. tachy, hyper etc

D Complete the ADDS score for each vital sign recorded at 06:30 in the table below, then total the ADDS score.

E Note the ‘Actions Required' section of the ADDS chart and explain who should accompany Mr Marconi when he leaves the ward to go to the X-ray department.

• 4 Based on the patient history, discuss at least 4 different factors that may have contributed to his fall. E.g. medication side effects, complications due to health conditions, abnormal vital signs or environmental factors (75 -150 words)
• There is no fracture evident on the forearm X-ray, the RN bandages and elevates his arm to reduce swelling. The chest X-ray shows consolidation of fluid on his right lower lung. The doctor diagnoses right lower lobe pneumonia. Mr Marconi is transferred to medical ward at 08:05, he is offered breakfast on arrival.

5 Relate the diagnosis of pneumonia to the two stages of respiration - external respiration and gas transport. Include the following in your answer.
A Describe what occurs during normal:
1 external respiration
2. gas transport.

B Mr Marconi's blood results indicate that he has a low oxygen and high carbon dioxide, relate this finding to the effects of pneumonia on external respiration and gas transport.

6 Relate the pathophysiology of his condition to the reason for his elevated respiratory rate. Describe the steps involved in homeostasis of respiratory rate including the following aspects in your answer:

A Name the 2 respiratory gases detected in the blood, O2 and CO2.

B Name the receptor sites where these gases are detected.

C The location of the control centre

D Why Mr Marconi would have an increased respiratory rate due to pneumonia. (200 words)

7 A sputum test is ordered for culture and sensitivity (also called susceptibility). Describe what each of these tests are evaluating and how the results relate to medication prescription. (50-100 words)

You are administering 08:00 medications to Mr Marconi, You note that the Registered Nurse in Emergency has already administered his morning Lantus at 07:30. He is due for his Ramipril.

8 Describe the steps in the renin-angiotensin-aldosterone pathway (RAAS) and how Ramipril affects this process. (100-150 words)

Include in your answer the following factors:
a What triggers the release of renin in the kidneys?
b What substance does renin target in the liver?
c How is angiotensinogen converted to angiotensin I?
d What is the enzyme that converts angiotensin I to angiotensin II and where is this normally found?
e Discuss two effects that angiotensin II has on blood pressure.
f What action does Ramipril have on the RAAS pathway?

During the morning Mr Marconi seems quite despondent, sleeping most of the time. He is refusing to eat saying that he feels too sick and just wants to sleep. At 09:15 he suddenly becomes diaphoretic, the Enrolled Nurse records the vital signs on the ADDS chart. His bedside glucometer test measures the blood sugar level as 3.1mmol

9 Explain the effects of insulin on blood sugar. Include the target sites and function of insulin (100-
150 words)

10 Review the observation chart and events leading up to his deterioration (information in the grey boxes in the case study). Answer the following in relation to Mr Marconi's deterioration at 09:15

A List the vital signs recorded and identify the readings that are abnormal. (You only need to list the vital signs at the time he deteriorated Review bothpages of the ADDS vital signs chart)
B Review the events that have occurred during the morning (information in the grey boxes on this case study) and discuss the factors that contributed to his decreased level of consciousness (AVPU scale).
C Discuss the medication that may have caused him to deteriorate.