Ms
CASE STUDY VIII
Ms. Y is a 23-year-old woman who was feeling fine until the morning of admission, which she began having severe chills, vomiting, diarrhea, headache, and a fever of 40.3°C (104.5° F). The symptoms persisted throughout the day and caused her to seek medical attention at the emergency room about 6 pm. Ms. Y had a intrauterine device (IUD) inserted at a local family planning clinic three days prior to admission. At the time of admission she denied shortness of breath, wheezing, sputum production, cough, hemoptysis, orthopnea, chest pain; illicit drug use; and exposure to tuberculosis.
After removal of the IUD, she was started on IV antibiotic therapy and a uterine swab was obtained, which showed a gram-negative cocci. Twelve hours after admission, she began complaining of increased shortness of breath. Respiratory rate was 34/minute, heart rate of 120/minute, and temperature of 39.6°C. She was using her accessory muscles to breathe, and chest auscultation revealed fine, inspiratory crackles bilaterally.
An ABG was obtained which showed the following results: pH 7.25, PaCO2 21 torr, PaO2 62 torr, HCO3- 9 mEq/L, and SaO2 88% on room air. Based on these ABG results, the patient was placed on nasal cannula at 3 L/min.
Over the next 8 hours, the patient continued to experience severe respiratory distress, and was transferred to the ICU and placed on an FIO2 of 0.6 by entrainment device with a repeat ABG showing the following: pH 7.26, PaCO2 35 mm Hg, PaO2 49 mm Hg, and a HCO3- 16 mEq/L. Her respiratory rate was 38/minute and her heart rate was 134/minute. A portable chest x-ray was obtained and shown to the right.
Prepare a SOAP note based upon the most recent presentation. Give specific pathophysiologic causes of the abnormal objective and subjective findings as part of your assessment and list specific respiratory care protocols which would be appropriate for this patient (include medications if appropriate).
QUESTIONS:
o How would you interpret the ABGs?
o What is the most likely explanation for the sudden onset of dyspnea, tachypnea, and tachycardia?
o What intervention would you recommend at this time?
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