Patient presents...
35 y/o African American female presents with generalized pain 10/10. On chronic pain medication, currently not effective. Abnormal CBC.
*May ask clarifying questions for additional info*
What is sickle cell crisis?
Name at least 5 anticipated orders for pt c/o SOB, spO2 75 on RA, HR 120, hx COPD, smoking, CAD, HTN
Can include medications, nursing interventions, consults, education, lab work, imaging, etc
Oxygen, Respiratory Therapy & breathing tx, empiric ABX, oral/IV steroids, CXR for PNA, use of IS, ABG, smoking cessation education, nicotine patch/gum, CBC (polycythemia) (elevated WBC)
Beta blockers
Pt came in for N/V/D x4 days. Poor oral intake and appetite. Pt reports she "thinks she ate some bad shrimp" at the buffet. On admit, pt K 3.0, Na 130, BP 110/70 and HR 95. Electrolytes repleted and pt started on IV fluids. Pt continues to have N/V despite antiemetics. Pt now c/o fatigue, weakness, and anxiety. You retake her vitals, BP 70/40, HR 125. Pt went from AAOx4 to now somnolent and needing stimulation to remain awake. MD orders STAT labs, BMP reveals AKI, elevated AST/ALT, and pt U/O has decreased over the last 6 hrs. What's happening??
Bonus: If left untreated, what could this progress to?
Hypovolemic shock r/t N/V/D, with end organ dysfunction
Bonus: MODS
Increased volume, pressure, workload causing increased heart muscle size, less compliant chambers, possible decreased cardiac output
Cardiomyopathy/hypertrophy
45 y/o male presents with dizziness, lightheadedness, and syncopal episode. Reports getting up to do something and woke up on the floor. Currently AAOx4, sitting in chair, BP 120/80. Significant hx of HTN, on mutliple antihypertensives.
*May ask questions for additional information*
What is orthostatic hypotension?
Name at least 5 anticipated orders for a patient c/o urinary frequency, urgency and dysuria, elderly and confused, BIB by spouse stating "he's been acting strange"
Can include labs, imaging, meds, teaching, consults, interventions
Urinalysis and culture, ABX, fluids, CBC (WBC), BMP (electrolytes, kidney fxn), renal US, bladder scan, foley/condom cath/straight cath PRN, pyridium, flomax, I/O, lactic acid, BP/HR/temp, orientation reassessments, monitor urine color, clarity, smell, etc
HMG-CoA reductase inhibitors are also called what? Used commonly for patients with CAD, stroke, MI, HTN, DM, usually with what other comorbidity?
Statins! Secondary to hyperlipidemia
Pt admitted for ETOH withdrawal. Current CIWA ranging from 12-18, getting Ativan as ordered. Pt Mg on admit 1.2. IV Mag ordered but hasn't come up from pharmacy yet. Admitting EKG showing sinus tachycardia with prolonged QT. Pt getting Zofran for N/V r/t withdrawal. They call a "monitor check" overhead for this patient and you find them on the floor. They are still conscious but c/o dizziness and palpitations, reports they stood up to use urinal, got dizzy and fainted. EKG tech is hooking the patient up to see....What is the likely cause??
Torsades de pointes/polymorphic v-tach r/t low mag levels, prolonged QT, use of antiemetics
Abberant electrical impulse causes erratic atrial conduction leading to an irregular cardiac rhythm, decreased cardiac output, increased risk for thromboembolic event
Atrial fib/flutter
75 y/o male presents with chest pain, palpitations, SOB, dizziness. Recently hospitalized r/t sepsis, discharged x1 week ago. Symptoms started shortly after getting home. Current vitals: 98.6, HR 150, BP 100/67, RR 24
*May ask questions for additional information*
What is atrial fibrillation? (With RVR)
Name at least 5 anticipated orders for patient presenting with chest pain 5/10 acute onset, central chest pain radiating to arm, hx CAD, HTN, noncompliant with meds, current vitals: 165/70, HR 100, pt AAOx4, diaphoretic, holding chest
Can include labs, imaging, meds, teaching, consults, interventions
MONA protocol: morphine, asa, nitro, oxygen, EKG, reperfusion--cath lab for stent, anticoags, BP control meds, echo, statin, troponins, d-dimer, CBC (WBC, H&H, PLT), coags, CXR, compliance education, ambulation, lifestyle changes
These two antiplatelets are often prescribed together for patients with CAD, MI, stroke, hyperlipidemia and other risk factors/comorbidities
Plavix/clopridogel and aspirin
Pt admitted with CP, lethargy, fever. Elevated WBC. CXR, echo, EKG all confirm endocarditis. Vegetations noted. Blood cultures drawn, + bacteria. Hx IV drug use. Pt getting ABX, tylenol PRN for fever. Pt was doing well, however overnight pt suddenly c/o extreme CP, SOB, anxiety and "impending doom" feeling, HR, temp, BP elevated. What's happening??
Septic emboli! Causing pulmonary embolism, loss of blood/O2 flow (ischemia)= pain, impaired gas exchange, etc.
Genetic alpha 1 antitrypsin deficiency or environmental/behavioral injury to lungs leading to: Alveolar destruction/damage-->air trapping-->impaired gas exchange and/or bronchial inflammation with increased mucus production-->narrowed airways-->airway obstruction
89 y/o male presents after being found down at home. Unknown downtime. Pt reports falling and being unable to get up and he does not have a Life Alert. Pt's neighbor called EMS after noticing pt had not come outside x3 days. Elevated CPK on admission, IV hydration ordered, Foley inserted with minimal output, tea colored urine.
*May ask questions for additional information*
What is rhabdomyolysis?
Name at least 5 anticipated orders for patient presenting with unilateral weakness, facial drooping, transient confusion, hx of CAD, HTN, DM, hyperlipidemia, afib (all recently dx)
Can include labs, imaging, meds, teaching, consults, interventions
Stroke/NIH scale, aspirin, TPA if applicable, thrombectomy if applicable, statin therapy, head CT/MRI, speech, PT/OT, heparin drip/lovenox/anticoags, BP control, safety precautions, neuro checks, coag labs, EKG/echo
This medication is given to patients in alcohol withdrawal as a discharge medication; often tapered dose; can be given concurrently with CIWA scale medication
Pt comes in with CP 7/10, radiating to back. EKG and troponins negative for MI. CXR shows cardiomegaly, enlarged cardiac/aortic silohoutte. Pain not responsive to current medications. BP and HR elevated, but haven't been rechecked in a while. Pt reports "crushing" sensation. What do you do? What do you think is happening?
BP differs on both arms. CT scan ordered revealing aorta with active dissection.
Type A (emergency surgical intervention) "which is the more common and dangerous of the two and involves a tear in the part of the aorta where it exits the heart or a tear in the upper, or ascending aorta, which may extend into the abdomen"
Type B (BP management) "which involves a tear in the lower, or descending, aorta only, which may also extend into the abdomen"
Atherosclerosis, clot formation, MI, stroke, DVT
54 y/o female admitted to telemetry for wound infection. Vitals stable overnight but pt now tachycardic, hypertensive, diaphoretic, and flushed. Significant hx of paraplegia r/t auto accident, neurogenic bladder, wheelchair dependent. Requires digital stimulation for bowel movements.
*May ask questions for additional information*
What is autonomic dysreflexia?
Name at least 5 anticipated orders for patient c/o SOB, orthopnea, lower extremity swelling, JVD; hx HTN, cardiomyopathy
Can include labs, imaging, meds, teaching, consults, interventions
CXR, lasix/diuresis, I/O, potassium, BMP, BNP, echo/EKG, troponin, TED hose, ambulation, raise legs up, monitor BP closely, decrease workload (beta blocker), HTN control, decrease salt intake, lifestyle changes/teaching, daily weights, O2 PRN, lung sounds
These medications are given together IV for hyperkalemia; the first med (normally found in the body) drives potassium into the cell
Insulin and D50
Pt c/o unilateral leg pain 3/10 and swelling secondary to crushing his leg at work. Vascular US negative for DVT. Extremity xray shows long bone fracture of tibia and fibula. Surgery consulted, declines need for surgical intervention at this time. Pain management, PT/OT ordered. Pt starts to develop increased pain 12/10, swelling, and now redness to affected limb. Pedal pulse was 2+ and now non-palpable, faint with Doppler. What else can you assess? What's happening?!
Bonus: what is the treatment?
Assess your P's: pallor, pain, pulselessness, parasthesias, paralysis. Compartment syndrome!
Bonus: Fasciotomy
Injury/infection-->cytokine release-->vasodilation-->transport of inflammatory mediators-->increased capillary membrane permeability-->fluid shift-->vascular dehydration-->hypotension-->lack of blood/O2 to cells--> anaerobic metabolism
Bonus: if this process is refractory to fluid resuscitation and requires vasopressors, it is called what?
Lactic acid production secondary to sepsis
Bonus: septic shock!