CASE STUDY
Mr. Bedford, a 28-year-old gentleman presents to the emergency department (ED) at 0300 hours with worsening shortness of breath since midnight. Complains of right sided-pleuritic chest pain and persistent productive cough. Talking in words, audible wheeze, appears dyspneic, tripoding.
Appears unwell.
Past Medical History: Asthma since 8 years of age. Eczema.
Medications: budesonide at 320 μg + formoterol at 9 μg b.i.d. combination and T. Prednisolone 30 mg/day for the last 5 months.
A-G Assessment:
Airway – Patent
Breathing – Spontaneous, RR-38/mt, SPO2-77% RA, decreased lung sounds left lower lobe, bilateral diffuse, high-pitched wheeze
Circulation – Appears flushed in face and neck, BP-136/92 mmHg, HR- 122/mt, dry mucous membranes, S1 S2 normal
Disability – Glasgow coma score (GCS) 14 – E4V4M6, not oriented to time, place or person, PEARL (pupils equal and reactant to light) – 3mm
Exposure – Needed support to walk from waiting room to bed space. Unable to lie supine, tripoding. Temperature 38.9 degrees Celsius. Abdomen soft, no organomegaly, peripheries cold, centrally warm. Nil edema.
Fluids – Unable to tolerate oral fluids, NBM for now
Glucose – BGL 6.0 mmol/L
Investigations:
Bloods- WCC- 11,000/mm3 with 38% neutrophils, 8% lymphocytes, 18 % monocytes and 35% bands; Serum sodium-125 mmol/L, potassium- 3 mmol/L, chloride -91 mmol/L, bicarbonate- 21 mmol/L, blood urea nitrogen- 14 mg /dl, serum creatinine – 0.6 mg/dl
2D transthoracic ECHO of the heart showed normal valves and an ejection fraction of 65% with a normal left ventricular end-diastolic pressure and normal left atrial size.
Unable to perform Spirometry
Arterial blood gas (ABG) analysis performed on room air: pH 7.49, PaCO2 29 mm Hg, PaO2 49 mm Hg.
Additional Information: Sputum cultures showed moderate growth of Pasteurella multocida.
Diagnosis: Hypoxemic Respiratory Failure secondary to acute exacerbation of asthma
A MET call was made at 0400hrs
QUESTIONS
Q1. Explain in the high priority clinical manifestations that have resulted in the escalation to MET call using a primary survey format.
Q2. Describe the pathophysiological link to the identified high priority clinical manifestations and the disease conditions that the patient has.
Q3. Discuss the pathophysiological link between the multiple disease conditions that the deteriorating patient has and the clinical presentation.
Q4. Discuss TWO diagnostic results and relate it to the underlying pathophysiology.
Q5. Explain THREE high priority interventions you will do to improve the patient’s clinical condition.
Q6. Discuss the pharmacological actions of TWO drugs that could be used in the management of this patient’s acute deterioration.
